Improving access to psychological therapies in England
Authors: Graham Thornicroft
Journal: The Lancet (2017)

Most people with mental illness worldwide receive no treatment at all.1Wang PS Aguilar-Gaxiola S Alonso J et al.Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys.Lancet. 2007; 370: 841-850Summary Full Text Full Text PDF PubMed Scopus (1049) Google Scholar The number benefiting from effective treatment is even fewer—eg, as low as one in six people with major depression receive effective care in high-income countries, and one in 27 people in low-income or middle-income countries.2Thornicroft G Chatterji S Evans-Lacko S et al.Undertreatment of people with major depressive disorder in 21 countries.Br J Psychiatry. 2017; 210: 119-124Crossref PubMed Scopus (427) Google Scholar For mild-to-moderate depression, the treatments of choice are psychological therapies.3WHOmhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: mental health Gap Action Programme (mhGAP); version 2.0. World Health Organization, Geneva2016Google Scholar, 4Singla DR Kohrt BA Murray LK Anand A Chorpita BF Patel V Psychological treatments for the world: lessons from low and middle income countries.Annu Rev Clin Psychol. 2017; 13: 149-181Crossref PubMed Scopus (329) Google Scholar Are there any examples of a health-care system successfully scaling up evidence-based practice for such common mental disorders? Yes: evidence is emerging that the Improving Access to Psychological Therapies (IAPT) programme in England fits this bill as reported by David M Clark and colleagues in The Lancet.5Clark DM Canvin L Green J Layard R Pilling S Janecka M Transparency about the outcomes of mental health services (IAPT approach): an analysis of public data.Lancet. 2017; (published online Dec 7.)http://dx.doi.org/10.1016/S0140-6736(17)32133-5Summary Full Text Full Text PDF Scopus (153) Google Scholar Launched in 2008, the IAPT programme provides psychological treatment centres across the country and these centres offer individual or group therapies—largely cognitive-behavioural treatment (CBT) approaches—to people with anxiety or depressive diagnoses.6Clark DM Layard R Smithies R Richards DA Suckling R Wright B Improving access to psychological therapy: initial evaluation of two UK demonstration sites.Behav Res Ther. 2009; 47: 910-920Crossref PubMed Scopus (413) Google Scholar Initial assessment, often by phone, determines whether a client is suitable for IAPT, needs low-intensity or high-intensity therapy, or needs to be referred to specialist mental health services. The programme is unusual because of several features. First, standardised and manualised evidence-based intervention protocols are used, with intensive clinical supervision. Second, routine outcome monitoring occurs at each clinical session with the results fed back to staff and clients. Third, treatment is free at the point of care with the service funded by the tax-based National Health Service, with 209 teams distributed across the country (with an investment of £400 million from 2011 to 2015).7Department of HealthWaiting times for talking therapies.https://www.gov.uk/government/news/waiting-times-for-talking-therapiesDate: Aug 2, 2011Google Scholar Fourth, clients might receive both psychological and pharmacological treatment at the same time. Finally, the IAPT programme aims to achieve quantified access and recovery rates. The scale of the programme is remarkable, with the latest data showing that about 950 000 people a year access IAPT for an initial assessment and advice, of whom more than 537 000 receive a course of therapy.8Baker C Mental health problems: statistics on prevalence and services. House of Commons Library. Briefing paper Number 6988.http://researchbriefings.parliament.uk/ResearchBriefing/Summary/SN06988Date: Jan 18, 2017Google Scholar Clark and colleagues' study5Clark DM Canvin L Green J Layard R Pilling S Janecka M Transparency about the outcomes of mental health services (IAPT approach): an analysis of public data.Lancet. 2017; (published online Dec 7.)http://dx.doi.org/10.1016/S0140-6736(17)32133-5Summary Full Text Full Text PDF Scopus (153) Google Scholar reports how service-level characteristics, such as the waiting times at individual IAPT teams, affect the outcomes of care and they show that better outcomes are not only associated with practitioner-level factors but also that service-level characteristics influence outcomes. With the IAPT programme, clients with clinical diagnoses had positive effects, treatment sessions increased, and some teams were able to accept more referrals. Conversely, outcomes were worse when waiting times were longer and when fewer therapy sessions were attended. However, much more is still needed. The original prospectus for IAPT relied heavily on delivering a strong return on investment from reductions in “presenteeism and absenteeism”,9Layard R Clark DM Why more psychological therapy would cost nothing.Front Psychol. 2015; 6: 1713Crossref PubMed Scopus (31) Google Scholar namely greater workplace productivity as a result of the treatment of employed people with anxiety or depression. However, little evidence has emerged that such productivity gains have been realised.10Radhakrishnan M Hammond G Jones PB Watson A McMillan-Shields F Lafortune L Cost of Improving Access to Psychological Therapies (IAPT) programme: an analysis of cost of session, treatment and recovery in selected Primary Care Trusts in the East of England region.Behav Res Ther. 2013; 51: 37-45Crossref PubMed Scopus (45) Google Scholar, 11McCrone P IAPT is probably not cost-effective.Br J Psychiatry. 2013; 202: 383Crossref PubMed Scopus (9) Google Scholar In terms of access, in many countries about a half of all people with anxiety or depression either do not consider that they have a difficulty or choose not to attend treatment sessions.2Thornicroft G Chatterji S Evans-Lacko S et al.Undertreatment of people with major depressive disorder in 21 countries.Br J Psychiatry. 2017; 210: 119-124Crossref PubMed Scopus (427) Google Scholar Therefore, system-wide measures are needed to increase help-seeking.12Clement S Schauman O Graham T et al.What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies.Psychol Med. 2015; 45: 11-27Crossref PubMed Scopus (1433) Google Scholar Avoidance or reduction of disparities in the access to therapy is also vital—eg, related to age, gender, ethnicity, or social position. The expansion of the range of evidence-based psychological therapies provided, from the original focus on CBT, now needs to be accelerated,13Meadows J Kellett S Development and evaluation of Cognitive Analytic Guided Self-Help (CAT-SH) for use in IAPT services.Behav Cogn Psychother. 2017; 45: 266-284Crossref PubMed Scopus (12) Google Scholar along with an intensification of the provision for children and young people, older adults, and people with psychotic disorders.14Fornells-Ambrojo M Johns L Onwumere J et al.Experiences of outcome monitoring in service users with psychosis: findings from an Improving Access to Psychological Therapies for people with Severe Mental Illness (IAPT-SMI) demonstration site.Br J Clin Psychol. 2017; 56: 253-272Crossref PubMed Scopus (20) Google Scholar Increasing recognition of syndemics suggests that IAPT services need to explicitly address comorbid mental and physical conditions.15Wroe AL Rennie EW Gibbons S Hassy A Chapman JE IAPT and long term medical conditions: what can we offer?.Behav Cogn Psychother. 2015; 43: 412-425Crossref PubMed Scopus (10) Google Scholar Although IAPT teams in England are likely to have made important contributions to the recently increasing treatment rates for adults with anxiety or depression (from 24% in 2007, to 37% in 2014),16McManus S Bebbington P Jenkins R Brugha T Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. NHS Digital, Leeds2016Google Scholar the longer-term goal for all services provided for people with mental illness must show real reductions in the overall prevalence of mental health problems.17Jorm AF Patten SB Brugha TS Mojtabai R Has increased provision of treatment reduced the prevalence of common mental disorders? Review of the evidence from four countries.World Psychiatry. 2017; 16: 90-99Crossref PubMed Scopus (255) Google Scholar I collaborate with Article author Richard Layard on initiatives related to global mental health, and I receive no payment or remuneration for this work. I declare no other competing interests. I thank Katarina Gerocova, a current IAPT practitioner, for discussion about how the programme actually works on the ground; this discussion informed my Comment. Transparency about the outcomes of mental health services (IAPT approach): an analysis of public dataTraditionally, efforts to improve mental health outcomes have largely focused on the development of new and more effective treatments. Our analyses show that the way psychological therapy services are implemented could be similarly important. Mental health services elsewhere in the UK and in other countries might benefit from adopting IAPT's approach to recording and publicly reporting clinical outcomes. Full-Text PDF Open AccessImprove access to quality primary care for patients with anxiety or depressionGraham Thornicroft (Feb 17, 2017, p 636)1 suggests that teams working on the Improving Access to Psychological Therapies (IAPT) programmes have helped increase treatment rates for adults with anxiety or depression (from 24% in 2007, to 37% in 2014).2 However, from a primary care perspective, the proportion of people with these disorders who receive psychological therapy is still small. Full-Text PDF Improve access to quality primary care for patients with anxiety or depression – Authors' replyWe thank Tony Kendrick for raising the important issue of how few people with anxiety or depression in the UK actually receive any treatment. In high-income countries like the UK, psychological treatment services, such as the Improving Access to Psychological Therapies (IAPT) programme, have an important role in increasing choice and access to evidence-based treatments, alongside strengthening primary care. Full-Text PDF