Background
Methods
Aims
Setting and participants
Tier | Description |
---|---|
Tier 1 | Staff in Tier 1 are not mental health specialists (they are GPs, school nurses, etc.). They offer general advice and treatment for less severe mental health problems, mental health promotion and identification of problems early in their development that require more specialist services |
Tier 2 | Tier 2 are CAMHS specialists working in community and primary care settings who provide assessment and treatment to patients experiencing mental health difficulties, training to practitioners in Tier 1 and outreach to identify severe or complex needs requiring more specialist interventions |
Tier 3 | Tier 3 are multidisciplinary teams working in the community, providing a specialised service for patients with more severe, complex and/or persistent disorders |
Tier 4 | Tier 4 provides services for patients with the most serious difficulties and includes highly specialised outpatient teams, day or inpatient units |
Study design and data collection methods
Pseudonym | Tier | Affiliation |
---|---|---|
Joan | 2 | Specialised |
Claire | 2 | Managerial |
Leanne | 3 | Junior |
Jackie | 3 | Psychology/managerial |
Judy | 3 | Managerial |
Sarah | 3 | Psychology |
Researcher dispositions
Analysis
Results
Theme | Description |
---|---|
Non-clinically orientated variance in practice | This theme involves changes to practice described by staff, including the rationale for treatment decisions that are often based upon resource availability rather than clinical need |
Diagnosis | This theme consists of staff beliefs and behaviours relating to the treatment and diagnosis of depression |
Capacity | This theme consists of the time to engage with research or to attend training and space to psychologically consider or incorporate learning into practice |
Staff economy | This theme was characterised by staff changes and shortages |
Non-clinically orientated variance in practice
Impact of staff backgrounds
‘I think ’cos we do tend to go and do different things. We’re all different backgrounds, PMHWs and we all have different ways of treating people’.
‘We’ve had some CAMHS staff that has been off to do IAPT so they have been trained in CBT… there’s a lot of the staff that’s got that awareness level of CBT so although they can’t use CBT in, in such form they can use approaches of CBT’ [Claire]‘[To improve current practice: young people need] access across the board to someone who’s CBT-trained and if they’re not getting that then I would kind of be asking what are they getting from a clinician who isn’t CBT-trained? But whether they’ve kind of obviously picked up the principles and haven’t had formal training but they’ve of done kind of workshops and that kind of thing and just from experience because they’ve been in CAMHS for 20/30 years kind of thing. That they’re able to kind of, I suppose they know what they are doing and what’s worked in the past for their clients with depression’ [Leanne]
‘Depression is, if you don’t deal with it early on, it can reoccur and it, it can be really debilitating for people so we need to tackle it and treat it at this early stage. I don’t have a concern with it being treated in Tier 2, I do have a concern with it being dealt with in Tier 2 by staff who aren’t trained in the treatments for it’ [Jackie]
Impact of a stretched service
‘[I]t depends on what information we get and it depends on what staff we’ve got. If it’s a young person that they, you know that’s presenting with some depression and we haven’t got a CBT appointment then we’ll put them into another appointment’ [Judy]‘[Well I suppose it would depend on the clinician individual approach…] adhering to the guidelines really and I suppose young people being assigned to the most appropriate people for their difficulties. I know that doesn’t always happen because of the sheer volume of referrals and lack of capacity with staff that we’ve got’ [Leanne]‘[T]he really bad point is really that if we need specific CBT … we then have to put it into ier 3 for them to have that because actually we haven’t got enough CBT practitioners in tier 2 but that doesn’t, that doesn’t mean that the young person should be in tier 3. It’s just, that’s the only way they access CBT’ [Claire]
Diagnosis
‘No in Tier 2 we wouldn’t diagnose depression. We would obviously pick up the signs and symptoms from the young person’s presentation and the ROMs [Routine Outcome Measures]. Using tools, but if they wanted a clinical diagnosis of depression then it would have to go to a consultant in specialist CAMHS’ [Claire]
‘Often people send [patients] to a medic [psychiatrist] because they want the medic to make the decision because they don’t feel confident doing it themselves’ [Sarah]
‘When you talk about depression though, do you mean clinical depression, that’s got a diagnosis?’ [Joan]‘Not if it’s clinical depression, no we wouldn’t, no we would treat low mood but young people will often tell you that they’re depressed without having the diagnosis criteria for depression …’ [Joan]
‘I think the risky ones regarding the depression are the ones that have carried out an act of suicide or significant serious self-harm. We do have a lot that remains in Tier 2 that is low-level self-harm linked to the low mood and depression but we tend to keep them in Tier 2’ [Claire]‘We wouldn’t normally treat people in Tier 2 who’ve got a diagnosis of clinical depression’ [Joan]‘I think if we could, I think depression probably shouldn’t sit in Tier 2. I think it should sit in Tier 3. But I think we should have more people in Tier 3 so that if Tier 2 gets a whiff of depression they’re not keeping it, they can pass it straight in’ [Sarah]
‘I have to say that I tend not to keep people who have [depression], particularly if they think they’re depressed. Low mood I might keep them for a little while but I’d tend to pass them on. I’m quite risk averse really. And not being mental health trained…’ [Joan]‘I think that by highlighting to people that what they are dealing with is depression then it might raise their anxieties a little bit’ [Jackie]
Capacity
Psychological capacity
‘Possibly staff uptake as well. I do think they would really want to do it and find it helpful but it’s gunna be the way that they are approached really because, headspace. If you catch someone on a difficult day and they’re back to back with clients they might not have room in their head to think about something else but if it’s done kind of obviously on a convenient day and just kind of putting it to them in the right way’ [Leanne]
‘From my experience it’s about support and I think that if … you give that person the time, the opportunity to not only do the training but them to put it into practice and they get the outcomes and feel much better about it. There’s lots of times where people have gone and asked for training, gone off and done the training and come back and not done anything with it’‘I think given the pressures on the service, the demand of the referrals that are coming in. It’s not always easy to put things into practice’
Time
‘I think there is always kind of room for more treatments and things. Particularly with it being so easy to kind of train in, so obviously just five days which is a lot easier to squeeze into someone’s diary than doing a diploma for a year or something’ [Leanne]‘I suppose fitting in the kind of time to do it in their diary. I know it is only five days but with clinicians being booked up quite far in advance it will have to be kind of planned quite early on I think’ [Leanne]‘There is quite a lot of training around but it’s having the time to do it often’ [Joan]
‘My concerns are that the staff are overwhelmed and busy and doing all sorts of other things and I’m hoping that the managers have remembered that they are doing this BA training and that they’ve left time and space for it…’ [Jackie]
Staff economy
‘[A] lot is outside our control such as staffing budgets but to remain focussed on what we can control – in the sessions with our clients to be the most effective clinicians we can be’ [Minutes of Meeting]
‘At the moment, the staffing is quite difficult and the numbers are quite difficult’ [Joan]‘With staff numbers kind of becoming reduced over the previous year and going forward because we do have staff members leaving. Staff members reducing to kind of part-time hours when they’ve previously been full-time’ [Leanne]
‘I guess the only issue [with a trial running in the service] … would be, is if it feels like people are getting taken out of the team again. So if there’s any, where people were “oh I can’t do this or I can’t do that”, people will resent that’ [Sarah]
‘Just because of the pressures, I have to admit the workers within our team have got a conscience so actually if they gunna be out of the building four days they know that actually when they come back they’ve either got four days of referrals to look at, four days of telephone calls to ring back, four days of appointments to either cancel or rearrange so actually if we do it in blocks of two, two days here and then in a couple of weeks, two days here or one day or whatever … least that would be split nicely in the diaries so they don’t feel that it’s a huge pressure taken out’ [Claire]
Implications for the trial design
Theme | Evidence | Implication for planned trial | ||
---|---|---|---|---|
Non-clinically orientated variation in practice and diagnosis | Differing staff backgrounds | Selection of an appropriate control arm | Stratified Randomisation by Tier | Recruitment of a variety of staff from both Tier 2 and Tier 3 |
Differing staff training experiences | ||||
Staff economy | Staff turnover/job role fluidity | Recruitment of excess staff | ||
Non-clinically orientated variation in practice, staff economy and capacity | Lack of staff capacity/staff stress | Five days of training split over several weeks and planned several months in advance | Self-selected sample | |
Capacity | Feedback from training to team | Cluster randomisation to reduce treatment contamination | ||
Non-clinically orientated variation in practice | Informal staff supervision | |||
Informal learning of therapeutic skills | Group supervision to facilitate learning | |||
Capacity | Headspace | Five days of training split over several weeks and planned several months in advance | ||
Diagnosis | Lack of staff confidence | Use of a structured interview tool to provide a DSM diagnosis by research team | ||
Lack of diagnoses | ||||
Non-clinically orientated variation in practice and staff economy | Speed of patient treatment | Reduce treatment delay and recruitment speed by adding additional study sites | ||
Diagnosis | Comorbidities | Participant inclusion criteria to include comorbidities | ||
Diagnosis and staff economy | Depression treated in both Tiers | Recruitment across Tier 2 and Tier 3 | Stratified randomisation by Tier | |
Non-clinically orientated variation in practice | Staff treatment preferences | Perceptions regarding delivery to be explored in qualitative interviews with staff and patients | ||
Staff economy and capacity | Staff and patient management | Attendance at regular management meeting | Informed recruitment strategy |