Commissioning stepped care for people with common mental health disorders

This is an extract from the commissioning guide. The complete commissioning guide is available at www.nice.org.uk/guidance/cmg41

5.2 Specifying step 2 services for people with subthreshold, mild and moderate common mental health disorders

5.2.1 Low-intensity psychological interventions
5.2.2 Pharmacological interventions

Commissioning services at step 2, underpinned by NICE guidance and quality standards, is likely to contribute to achieving the following service outcomes:

Reducing the stigma and discrimination associated with a diagnosis of, or treatment for, common mental health disorders.
Increasing the proportion of people who are identified, assessed and receive treatment in accordance with NICE guidance.
Improving the proportion of people who make a clinically significant improvement or recover.
Improving emotional wellbeing, quality of life and functional ability in people with common mental health disorders.
Improving service-user choice and experience of mental health services.
Improving the interface between services for people with common mental health disorders.

Table 10 summarises step 2 of the stepped-care model for common mental health disorders. The majority of people needing treatment for a common mental health disorder will need treatment in step 2.

Table 10 Step 2 services

Focus of the intervention	Nature of the intervention
Depression: persistent subthreshold depressive symptoms or mild to moderate depression	Individual facilitated self-help Computerised cognitive behavioural therapy (CBT) Structured physical activity Group-based peer support (self-help) programmes(for people with depression and a chronic physical health condition) Non-directive counselling delivered at home (for women during pregnancy and the postnatal period) Antidepressants Self-help groups
Generalised anxiety disorder Panic disorder: mild to moderate panic disorder	Individual non-facilitated and facilitated self-help Psychoeducational groups Self-help groups
Obsessive-compulsive disorder: mild to moderate obsessive-compulsive disorder	Individual or group CBT (including exposure and response prevention [ERP]) (typically provided within step 3 services^a) Self-help groups
Post-traumatic stress disorder: including mild to moderate post-traumatic stress disorder.	Trauma-focused CBT (typically provided within step 3 services^a) Eye movement desensitising and reprocessing (EMDR) (typically provided within step 3 services^a)
All disorders	Support groups Educational and employment support services Referral for further assessment and interventions
^a These interventions may typically be commissioned from, and provided by, trained, high-intensity therapy staff in step 3 services (see section 5.3).

The Topic Advisory Group agreed that although there have been recent improvements in the awareness of common mental health disorder pathways at step 1 and the commissioning of psychological interventions at step 3, the greatest room for improvement remains in the commissioning of step 2 services. In many areas there is a high turnover of staff at step 2 and competition for resources with step 3 services.

The key service components when commissioning effective step 2 services are:

low intensity psychological interventions (see section 5.2.1)
pharmacological interventions (see section 5.2.2).

Advice for commissioning additional support services at steps 2 and 3 is provided in section 5.3.3.

Note that although there are some similarities in the key components of step 2 and 3 services there are significant differences in the unit costs of these services, which are clearly demonstrated in the commissioning and benchmarking tool. Commissioning sufficient capacity at step 2 may improve productivity by reducing inappropriate use of higher-intensity psychological interventions and inappropriate prescribing of antidepressants.

5.2.1 Low-intensity psychological interventions

Table 11 summarises the low-intensity psychological interventions recommended by NICE for each common mental health disorder at step 2.

Table 11 Low-intensity psychological interventions recommended at step 2

Psychological intervention	Disorder
Cognitive behavioural therapy (computerised)	Depression
Cognitive behavioural therapy (individual) including exposure and response prevention^a	Obsessive-compulsive disorder
Cognitive behavioural therapy (group) including exposure and response prevention^a	Obsessive-compulsive disorder
Cognitive behavioural therapy (trauma-focused)^a	Post-traumatic stress disorder
Eye movement desensitising and reprocessing^a	Post-traumatic stress disorder
Group-based peer support (self-help) programmes	Depression (with a chronic physical health condition)
Non-directive counselling delivered at home	Depression (antenatal and postnatal)^b
Psychoeducational groups	Generalised anxiety disorder Panic disorder
Self-help groups	Depression Generalised anxiety disorder Obsessive-compulsive disorder Panic disorder
Self help (individual facilitated)	Depression Generalised anxiety disorder Panic disorder
Self help (individual non-facilitated)	Generalised anxiety disorder Panic disorder
Structured physical activity	Depression
^a These interventions may typically be commissioned from, and provided by, trained, specialist staff in step 3 services (see section 5.3). ^bCommissioners may also wish to refer to the NICE commissioning guide 'Antenatal and postnatal mental health services' when developing services for this group

To ensure people have a choice of evidence-based psychological interventions at step 2, commissioners should:

use their local needs assessment (see section 4) to estimate the number of people who are likely to be offered and accept low-intensity psychological interventions at step 2
have plans that work towards commissioning adequate levels of all of the low intensity psychological interventions recommended by NICE
ensure that they commission a range of low-intensity psychological interventions that meet the needs of the whole population and enable people to make an informed choice of evidence-based interventions
specify that people have access to service-user-centred information to enable them to make an informed choice about which low-intensity psychological interventions, delivered by qualified providers, best meet their needs.

When commissioning low-intensity psychological interventions, commissioners may wish to:

begin by commissioning interventions for depression and generalised anxiety disorder, and interventions that are recommended for more than one condition, such as individual facilitated self-help, and for which there is likely to be the greatest demand
explore options for commissioning group-based activities, such as self-help groups and pscyhoeducational groups, that are cost effective in terms of service-user outcomes, increasing capacity and reducing waiting lists.

Commissioners should ensure that their providers of low-intensity psychological interventions can demonstrate cost effectiveness and high quality. This will include measures of the following:

Quality assurance: commissioners should ensure providers are meeting, or working towards meeting, the quality measures specified in the contract and NICE quality standards. They should ensure that providers follow NICE guidance on delivering low-intensity psychological interventions, including offering service users the recommended length, number and frequency of sessions (including additional sessions for followup and relapse prevention if indicated).
Use of validated tools: commissioners should ask providers to demonstrate that they use evidence-based assessment, monitoring and outcomes tools (such as the IAPT data standard, see section 3.3). Providers should also be able to demonstrate that psychological interventions are provided using competence frameworks or structured models developed from evidence-based treatment manuals.
Accessibility: commissioners should specify that services are accessible, for example providing services outside normal working hours, delivering interventions or assessments in a person's home and in accessible venues, and using appropriate technology (see section 3.5). Commissioners should be attentive to the location, time and accessibility of services (see also section 3.5.1). Technological solutions such as computerised cognitive behavioural therapy and phone-based services can be effectively used in step 2, and may reduce some of the costs associated with staff travel and room hire. Commissioners should work closely with providers when selecting the computerised cognitive behavioural therapy packages because license costs, service user preferences and service-user outcomes vary.
Workforce competencies: commissioners should specify that providers' staff:
- are trained to deliver any psychological therapies that they provide
- receive regular supervision from a person competent in both supervision and the intervention
- receive ongoing programmes of workforce or personal development, which may include the management of more complex cases such as people with common comorbidities. More experienced step 2 practitioners could receive training to provide assessments and referral and/or clinical supervision.
Unit cost: per service-user and per outcome. See the commissioning and benchmarking tool.

Commissioners may wish to refer to 'Guidance for Commissioning IAPT training 2011/12 to 2014/15' for further information about workforce development and training. Commissioners should note that staff who deliver psychological interventions at step 2 are commonly psychological wellbeing practitioners (PWPs) although other staff models may be appropriate, such as using graduate mental health or nursing staff. Commissioners should ensure that they commission adequate local capacity each year for psychological wellbeing practitioner training programmes.

5.2.2 Pharmacological interventions

Commissioners should be aware that antidepressants are not routinely recommended by NICE for managing common mental health disorders at step 2, but may be considered for people with:

a past history of moderate or severe depression
initial presentation of subthreshold depressive symptoms present for at least 2 years
subthreshold depressive symptoms or mild depression persisting after other interventions
mild depression that complicates the care of a physical health condition.

Commissioners should work with their medicines management team to examine the prescribing of antidepressants for people at step 2, and to explore the reasons behind any variations. Commissioners should:

ensure that their awareness-raising training for GPs (see section 5.1.1) includes information on NICE recommendations for antidepressants for people in step 2.
talk to GPs about their prescribing, and show them how it compares with their peers in the local clinical commissioning group, in terms of what and how they prescribe.