Improving Access to Psychological Therapies
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Improving Access to Psychological Therapies (IAPT), also known as
talking therapies Psychotherapy (also psychological therapy, talk therapy, or talking therapy) is the use of Psychology, psychological methods, particularly when based on regular Conversation, personal interaction, to help a person change behavior, increase hap ...
is a
National Health Service (England) The National Health Service (NHS) is the Publicly funded health care, publicly funded healthcare system in England, and one of the four National Health Service systems in the United Kingdom. It is the second largest single-payer healthcare s ...
initiative to provide more
psychotherapy Psychotherapy (also psychological therapy, talk therapy, or talking therapy) is the use of psychological methods, particularly when based on regular personal interaction, to help a person change behavior, increase happiness, and overcome pro ...
to the general population. It was developed and introduced by the Labour Party as a result of
economic evaluation Economic evaluation is the process of systematic identification, measurement and valuation of the inputs and outcomes of two alternative activities, and the subsequent comparative analysis of these. The purpose of economic evaluation is to identify ...
s by Professor Lord Richard Layard, based on new therapy guidelines from the
National Institute for Health and Care Excellence The National Institute for Health and Care Excellence (NICE) is an executive non-departmental public body of the Department of Health and Social Care in England that publishes guidelines in four areas: * the use of health technologies withi ...
as promoted by clinical psychologist
David M. Clark David Millar Clark, (born 20 August 1954) is a British psychologist. Career Clark was born in Darlington and studied experimental psychology at Oxford University. He trained as a clinical psychologist at the Institute of Psychiatry. He then retu ...
.


Aims

The aim of the project is to increase the provision of evidence-based treatments for common mental health conditions such as
anxiety Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
and depression by
primary care Primary care is the day-to-day healthcare given by a health care provider. Typically this provider acts as the first contact and principal point of continuing care for patients within a healthcare system, and coordinates other specialist care t ...
organisations. This includes
workforce planning The workforce or labour force is a concept referring to the pool of human beings either in employment or in unemployment. It is generally used to describe those working for a single company or industry, but can also apply to a geographic reg ...
to adequately train the mental health professionals required. This would be based on a 'stepped care' or triage model where 'low intensity' interventions or self-help would be provided to most people in the first instance and 'high intensity' interventions for more serious or complex conditions. Outcomes would be assessed by standardised questionnaires, where sufficiently high initial scores (a 'case') and sufficiently low scores immediately after treatment (below 'caseness'), would be classed as 'moving to recovery'. The NICE therapy guidelines presume reliable diagnosis. IAPT therapists do not make formal diagnoses. This calls into question IAPT's claimed fidelity to the NICE guidelines, particularly as it does not monitor therapists treatment adherence.


Evaluation

Initial demonstration sites reported outcomes in line with predictions in terms of the number of people treated (especially with 'low intensity' interventions such as 'guided self-help') and the percentages classified as recovered and as in more employment (a small minority) to ten months later. It was noted that the literature indicates a substantial proportion of patients would recover anyway with the passage of time or with a
placebo A placebo ( ) is a substance or treatment which is designed to have no therapeutic value. Common placebos include inert tablets (like sugar pills), inert injections (like Saline (medicine), saline), sham surgery, and other procedures. In general ...
– in fact the majority of those whose condition had lasted for less than six months, but only a small minority of those whose condition had been longer-lasting. There has been some debate over whether IAPT's roll-out may result initially in low quality therapy being offered by poorly trained practitioners. Beacon UK benchmarked IAPT performance across England for 2011–12 and reported that 533,550 people accessed (were referred to) IAPT services – 8.7% of people suffering from anxiety and depression disorders – with around 60% entering treatment sessions. Most local IAPT services did not reach the target of a 50% 'recovery' rate. In 2012–2013, 761,848 people were referred to IAPT services. 49% went into treatment (the rest either assessed as unsuitable for IAPT or declined), although around half of those dropped out before completing at least two sessions. Of the remainder, 127,060 people had pre-treatment and post-treatment mental health questionnaires submitted indicating 'recovery' – a headline rate of 43%. A report by the University of Chester indicated that sessions were costing three times more to fund than the original
Department of Health A health department or health ministry is a part of government which focuses on issues related to the general health of the citizenry. Subnational entities, such as states, counties and cities, often also operate a health department of their ow ...
estimates.One in two is pretty poor odds
Therapy Today, March 2014, Vol. 25 / Issue 2, Barry McInnes
For 2014-15 there were nearly 1.3 million referrals to IAPT, of which 815,665 entered treatment. Of those, 37% completed sufficient sessions, with 180,300 showing a 'reliable recovery' (on anxiety and depression questionnaires completed before and immediately after treatment) – which was just over one in five of those who entered treatment, just under half of those who completed enough sessions.Can call centre therapy solve the NHS mental health crisis?
The Guardian, Robert Booth, 25 January 2016
Opinion on IAPT remained divided. The number of trained IAPT therapists did not appear to have met the government's target of 6000, resulting in high caseloads. Some complained of seeing more 'revolving door' patients and excess complexity of cases, while the NHS has acknowledged problems with waiting times and recovery rates. However
Norman Lamb Sir Norman Peter Lamb (born 16 September 1957) is a British politician and solicitor. He was the Liberal Democrat Member of Parliament (MP) for North Norfolk from 2001 to 2019, and was the chair of the Science and Technology Select Committee ...
, who championed IAPT within the
coalition government 2010-2015 A coalition is a group formed when two or more people or groups temporarily work together to achieve a common goal. The term is most frequently used to denote a formation of power in political or economical spaces. Formation According to ''A Gui ...
, disagreed with picking faults with such an extensive and world-leading advance in evidence-based treatment. Others lauded the success in rising numbers of referrals, but warned of the failure to improve recovery rates. It was noted that both
antidepressant Antidepressants are a class of medication used to treat major depressive disorder, anxiety disorders, chronic pain conditions, and to help manage addictions. Common side-effects of antidepressants include dry mouth, weight gain, dizziness, hea ...
prescribing and psychiatric disability claims have continued to rise. In 2017 fewer than half of the
Clinical Commissioning Group Clinical commissioning groups (CCGs) were NHS organisations set up by the Health and Social Care Act 2012 to organise the delivery of NHS services in each of their local areas in England. On 1 July 2022 they were abolished and replaced by Integra ...
s met the target (15.8%) for the number of people who should be accessing talking therapies. There has been no publicly funded independent audit of IAPT . A study of 90 IAPT cases25 https://doi.org/10.1177/1359105318755264, cott (2018) IAPT - The Need for Radical Reform, Journal of Health Psychology, assessed with a 'gold standard' diagnostic interview revealed that only some recovered, in the sense of losing their diagnostic status. The results were identical whether or not the person was treated before or after personal injury litigation. Similarly, the use of the PHQ-9 in calculating recovery rates for treatment targets has been questioned considering the difficulty a significant minority of the population may have in understanding its content. In July 2021 55,703 appointments out of the total 434,000 which went ahead involved one or more practitioners who did not have an accredited IAPT qualification. There are about 2000 psychological wellbeing practitioners in the service, with another 1,200 trainees. They are supported by high intensity therapists and counsellors of which there are about 4,000 with 700 trainees. In 2022 less than 40% of people referred to IAPT services in some areas actually attended their initial assessment and first treatment sessions. Only 57% of people who attended for assessment went on to attend the first treatment appointment. People who self-referred were three times more likely to attend the assessment appointment than those who were referred by their GP.


Updates

In December 2010,
Paul Burstow Paul Kenneth Burstow (born 13 May 1962) is a British former politician who served as the Liberal Democrat Member of Parliament for Sutton and Cheam for 18 years, from 1997 to 2015, when he was defeated by Paul Scully. He was appointed Minis ...
, Minister for Care Services, announced an extension to the IAPT project to include Children and Young Peoples services. The government pledged £118m annually from 2015 to 2019 to increase access to psychological therapies services to children and young people. When the programme officially started in 2008 it was only for working age adults, but in 2010 it was opened to all ages. In 2015 Clark and fellow clinical psychologist
Peter Fonagy Peter Fonagy, (born 14 August 1952) is a Hungarian-born British psychoanalyst and clinical psychologist. He studied clinical psychology at University College London. He is Professor of Contemporary Psychoanalysis and Developmental Science and H ...
, writing in response to wide-ranging criticism from child and adolescent psychiatrist
Sami Timimi Sami Timimi is a British psychiatrist. He is a consultant in child and adolescent psychiatry, Director of medical education at Lincolnshire Partnership NHS Foundation Trust, and a visiting professor of child psychiatry at the University of Lincoln ...
, stated that IAPT now has increasing support for the non-CBT modalities recommended by NICE for depression:
counselling Counseling is the professional guidance of the individual by utilizing psychological methods especially in collecting case history data, using various techniques of the personal interview, and testing interests and aptitudes. This is a list of co ...
,
couples therapy Couples therapy (also couples' counseling, marriage counseling, or marriage therapy) attempts to improve romantic relationships and resolve interpersonal conflicts. History Marriage counseling originated in Germany in the 1920s as part of the eu ...
,
interpersonal psychotherapy Interpersonal psychotherapy (IPT) is a brief, attachment-focused psychotherapy that centers on resolving interpersonal problems and symptomatic recovery. It is an empirically supported treatment (EST) that follows a highly structured and time-limite ...
and brief psychodynamic therapy; and for Children and Young People (CYP-IAPT) more
systemic Systemic fundamental to a predominant social, economic, or political practice. This refers to: In medicine In medicine, ''systemic'' means affecting the whole body, or at least multiple organ systems. It is in contrast with ''topical'' or ''loc ...
family therapy Family therapy (also referred to as family counseling, family systems therapy, marriage and family therapy, couple and family therapy) is a branch of psychology and clinical social work that works with families and couples in intimate relationsh ...
, interpersonal therapy and parenting therapy is on the way. Timimi described the changes as still "light" on relational/collaborative therapy compared to the 'technical model' derived from 'eminence-based' NICE guidelines via inadequate diagnostic categories. A
Payment by Results Payment by Results (PbR) is a type of public policy instrument whereby payments are contingent on the independent verification of results. It is being actively promoted by a number of governments for more effective implementation of domestic policy. ...
system is being developed for IAPT, whereby each local
Clinical Commissioning Group Clinical commissioning groups (CCGs) were NHS organisations set up by the Health and Social Care Act 2012 to organise the delivery of NHS services in each of their local areas in England. On 1 July 2022 they were abolished and replaced by Integra ...
can reward each local provider according to various targets met for the service and for each client – particularly for how much change in scores on the self-report questionnaires. The March 2021 issue of the British Journal of Clinical Psychology has highlighted the considerable controversy over IAPT's claims of success, Scott( 2021)26 https://dx.doi.org/10.1111%2Fbjc.12264 and Kellett et al., (2021)27 have responded with their own commentary ‘The costs and benefits of practice-based evidence: Correcting some misunderstandings about the 10-year meta-analysis of IAPT studies’


History

Richard Layard Peter Richard Grenville Layard, Baron Layard FBA (born 15 March 1934) is a British labour economist, currently working as programme director of the Centre for Economic Performance at the London School of Economics. Layard was Senior Research ...
, a labour economist at the
London School of Economics , mottoeng = To understand the causes of things , established = , type = Public research university , endowment = £240.8 million (2021) , budget = £391.1 millio ...
, had become influential in
New Labour New Labour was a period in the history of the British Labour Party from the mid to late 1990s until 2010 under the leadership of Tony Blair and Gordon Brown. The name dates from a conference slogan first used by the party in 1994, later seen ...
party politics and was appointed to the
House of Lords The House of Lords, also known as the House of Peers, is the Bicameralism, upper house of the Parliament of the United Kingdom. Membership is by Life peer, appointment, Hereditary peer, heredity or Lords Spiritual, official function. Like the ...
in 2000. He had a particular interest in the happiness of populations and
mental health Mental health encompasses emotional, psychological, and social well-being, influencing cognition, perception, and behavior. It likewise determines how an individual handles stress, interpersonal relationships, and decision-making. Mental health ...
; his father,
John Layard John Willoughby Layard (27 November 1891 – 26 November 1974) was an English anthropologist and psychologist. Early life Layard was born in London, son of the essayist and literary writer George Somes Layard and his wife Eleanor. He grew up ...
, was an
anthropologist An anthropologist is a person engaged in the practice of anthropology. Anthropology is the study of aspects of humans within past and present societies. Social anthropology, cultural anthropology and philosophical anthropology study the norms and ...
who had survived suicidal depression and retrained as a Jungian psychologist after undergoing
psychoanalysis PsychoanalysisFrom Greek: + . is a set of theories and therapeutic techniques"What is psychoanalysis? Of course, one is supposed to answer that it is many things — a theory, a research method, a therapy, a body of knowledge. In what might b ...
by
Carl Jung Carl Gustav Jung ( ; ; 26 July 1875 – 6 June 1961) was a Swiss psychiatrist and psychoanalyst who founded analytical psychology. Jung's work has been influential in the fields of psychiatry, anthropology, archaeology, literature, philo ...
.Richard Layard on happiness, CBT and Christianity
April 19, 2013. Interview by Jules Evans, Centre for the History of the Emotions at Queen Mary, University of London
In 2003 Richard Layard met the
clinical psychologist Clinical psychology is an integration of social science, theory, and clinical knowledge for the purpose of understanding, preventing, and relieving psychologically based distress or dysfunction and to promote subjective well-being and persona ...
David M. Clark David Millar Clark, (born 20 August 1954) is a British psychologist. Career Clark was born in Darlington and studied experimental psychology at Oxford University. He trained as a clinical psychologist at the Institute of Psychiatry. He then retu ...
, a leading figure in
Cognitive Behavioral Therapy Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. CBT focuses on challenging and changing cognitive distortions (suc ...
who was running the Centre for Anxiety Disorders and Trauma (with Anke Ehlers and Paul Salkovskis) at the
Institute of Psychiatry The Institute of Psychiatry, Psychology and Neuroscience (IoPPN) is a research institution dedicated to discovering what causes mental illness and diseases of the brain. In addition, its aim is to help identify new treatments for them and ways ...
and
Maudsley Hospital The Maudsley Hospital is a British psychiatric hospital in south London. The Maudsley is the largest mental health training institution in the UK. It is part of South London and Maudsley NHS Foundation Trust, and works in partnership with the In ...
. Clark professed to high rates of improvement from CBT but low availability of the therapy despite
NICE Nice ( , ; Niçard: , classical norm, or , nonstandard, ; it, Nizza ; lij, Nissa; grc, Νίκαια; la, Nicaea) is the prefecture of the Alpes-Maritimes department in France. The Nice agglomeration extends far beyond the administrative c ...
guidelines now recommending it for several
mental disorders A mental disorder, also referred to as a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitti ...
. Layard, with Clark's help, set about campaigning for a new national service for NICE-recommended treatments, particularly CBT. One key argument was that it would be
cost-effective Cost-effectiveness analysis (CEA) is a form of economic analysis that compares the relative costs and outcomes (effects) of different courses of action. Cost-effectiveness analysis is distinct from cost–benefit analysis, which assigns a monetar ...
and indeed eventually pay for itself by increasing productivity and reducing state benefits such as
Disability Living Allowance Disability Living Allowance (DLA) is a social security benefit in the United Kingdom paid to eligible claimants who have personal care and/or mobility needs as a result of a mental or physical disability. It is tax-free, non-means-tested and non-c ...
and
Incapacity Benefit Incapacity Benefit was a British social security benefit that was paid to people facing extra barriers to work because of their long-term illness or their disability. It replaced Invalidity Benefit in 1995. The government began to phase out Inc ...
(which had seen rising claims since their introduction by
John Major Sir John Major (born 29 March 1943) is a British former politician who served as Prime Minister of the United Kingdom and Leader of the Conservative Party (UK), Leader of the Conservative Party from 1990 to 1997, and as Member of Parliament ...
's
Conservative Party The Conservative Party is a name used by many political parties around the world. These political parties are generally right-wing though their exact ideologies can range from center-right to far-right. Political parties called The Conservative P ...
in 1992 and 1995 respectively). The plan was accepted in principle by the newly re-elected Labour government in 2005 and gradually put into practice directed by Clark. Layard names several others as having helped gain the initial political traction for the initiative – MP
Ed Miliband Edward Samuel "Ed" Miliband (born 24 December 1969) is a British politician serving as Shadow Secretary of State for Climate Change and Net Zero since 2021. He has been the Member of Parliament (MP) for Doncaster North since 2005. Miliband ...
,
psychiatrist A psychiatrist is a physician who specializes in psychiatry, the branch of medicine devoted to the diagnosis, prevention, study, and treatment of mental disorders. Psychiatrists are physicians and evaluate patients to determine whether their sy ...
Louis Appleby Sir James Louis John Appleby (born 27 February 1955) is a British psychiatrist who leads the National Suicide Prevention Strategy for England and directs the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness ...
(then National Director for Mental Health),
David Halpern (psychologist) David Solomon Halpern (born June 1966) is a British civil servant, heading the Behavioural Insights Team (unofficially known as the Nudge Unit) spun out from the Cabinet Office (United Kingdom), Cabinet Office. Education Halpern attended King' ...
, psychiatrist
David Nutt David John Nutt (born 16 April 1951) is an English neuropsychopharmacologist specialising in the research of drugs that affect the brain and conditions such as addiction, anxiety, and sleep. He is the chairman of Drug Science, a non-profit w ...
, MP
Alan Milburn Alan Milburn (born 27 January 1958) is a British Labour Party politician who was Member of Parliament (MP) for Darlington from 1992 to 2010. He served for five years in the Cabinet, first as Chief Secretary to the Treasury from 1998 to 1999, a ...
(married to a psychiatrist) and eventually the PM
Gordon Brown James Gordon Brown (born 20 February 1951) is a British former politician who served as Prime Minister of the United Kingdom and Leader of the Labour Party (UK), Leader of the Labour Party from 2007 to 2010. He previously served as Chance ...
. In 2006 the Mental Health Policy Group at the LSE published 'The Depression Report', commonly referred to as the Layard Report, advocating for the expansion of psychotherapy on the NHS. This facilitated the development of IAPT initiatives, including two demonstration sites (pilot studies) and then training schemes for new types of psychological practitioner. The programme was officially announced in 2007 on
World Mental Health Day World Mental Health Day (10 October) is an international day for global mental health education, awareness and advocacy against social stigma. It was first celebrated in 1992 at the initiative of the World Federation for Mental Health, a global m ...
. Some
mental health professionals A mental health professional is a health care practitioner or social and human services provider who offers services for the purpose of improving an individual's mental health or to treat mental disorders. This broad category was developed as a ...
cast doubt on the claims early on. In the official publication of the
British Psychological Society The British Psychological Society (BPS) is a representative body for psychologists and psychology in the United Kingdom. History It was founded on 24 October 1901 at University College London (UCL) as ''The Psychological Society'', the organ ...
in 2009, experienced clinical psychologists John Marzillier and Professor John Hall strongly criticised IAPT's promoters for glossing over both the data gaps acknowledged in the NICE reports and the complexity of the multiple issues typically affecting people with mental health problems and their ability to sustain employment; they were met with much agreement as well as angry criticism. One researcher cited the UK initiative as the most impressive plan to disseminate stepped-care
cognitive behaviour therapy Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. CBT focuses on challenging and changing cognitive distortions (suc ...
. But the plan appears not to have worked, Davis (2020)28 in the Journal of Evidence Based Mental Health, noted that 73% of IAPT clients receive low intensity therapy first (guided self help, computer assisted CBT or group psychoeducation) but only 4% are transferred to high intensity therapy and the first transition appointment is the least well attended.


See also

*
Child and Adolescent Mental Health Services Child and Adolescent Mental Health Services (CAMHS) is the name for NHS-provided services in the United Kingdom for children, generally until school-leaving age, who are having difficulties with their emotional well-being or are deemed to have pe ...
*
National Mental Health Development Unit The National Mental Health Development Unit (NMHDU) was a governmental organisation in England charged with supporting the implementation of mental health policy. The unit worked to achieve this by advising on best practice for improving mental h ...
* Troubled Families scheme General: *
Mental health in the United Kingdom Mental health in the United Kingdom involves state, private and community sector intervention in mental health issues. One of the first countries to build asylums, the United Kingdom was also one of the first countries to turn away from them as ...


References

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Further reading


Common mental health problems: identification and pathways to care
NICE guidelines, May 2011
Some perspectives on improving access to psychological therapies (IAPT)
Charlotte Thomas, 2013.
The sorry state of NHS provision of psychological therapy.
Paul Atkinson, 2014


External links

* {{DEFAULTSORT:Improving Access To Psychological Therapies Mental health in England Psychotherapy Cognitive behavioral therapy Programmes of the Government of the United Kingdom