 |
Improving Access to Psychological Therapies (IAPT), also known as NHS Talking Therapies, for anxiety and depression, is a National Health Service initiative to provide more psychotherapy to the general population in England. It was developed and introduced by the Labour Party as a result of economic evaluations by Professor Lord Richard Layard, based on new therapy guidelines from the National Institute for Health and Care Excellence as promoted by clinical psychologist David M. Clark.
The aim of the project is to increase the provision of evidence-based treatments for common mental health conditions such as anxiety and depression by primary care organisations. This includes workforce planning to adequately train the mental health professionals required. [1] 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.
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. [2] [3] It was noted that the literature indicates a substantial proportion of patients would recover anyway with the passage of time or with a placebo – 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. [4]
There has been some debate over whether IAPT's roll-out may result initially in low quality therapy being offered by poorly trained practitioners. [5] [6]
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. [7]
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 estimates. [8]
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. [9] 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, who championed IAPT within the coalition government 2010-2015, disagreed with picking faults with such an extensive and world-leading advance in evidence-based treatment. [9] Others lauded the success in rising numbers of referrals, but warned of the failure to improve recovery rates. [10] It was noted that both antidepressant prescribing and psychiatric disability claims have continued to rise. [11]
In 2017 fewer than half of the Clinical Commissioning Groups met the target (15.8%) for the number of people who should be accessing talking therapies. [12] There has been no publicly funded independent audit of IAPT . A study of 90 IAPT cases25 https://doi.org/10.1177/1359105318755264, [Scott (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. [13]
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. [14]
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. [15]
In December 2010, Paul Burstow, 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. [16]
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, writing in response to wide-ranging criticism from child and adolescent psychiatrist Sami Timimi, [11] stated that IAPT now has increasing support for the non-CBT modalities recommended by NICE for depression: counselling, couples therapy, interpersonal psychotherapy and brief psychodynamic therapy; and for Children and Young People (CYP-IAPT) more systemic family therapy, interpersonal therapy and parenting therapy is on the way. [17] 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. [18]
A Payment by Results system is being developed for IAPT, whereby each local Clinical Commissioning Group 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. [19] 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’
Richard Layard, a labour economist at the London School of Economics, had become influential in New Labour party politics and was appointed to the House of Lords in 2000. He had a particular interest in the happiness of populations and mental health; his father, John Layard, was an anthropologist who had survived suicidal depression and retrained as a Jungian psychologist after undergoing psychoanalysis by Carl Jung. [20] In 2003 Richard Layard met the clinical psychologist David M. Clark, a leading figure in Cognitive Behavioral Therapy who was running the Centre for Anxiety Disorders and Trauma (with Anke Ehlers and Paul Salkovskis) at the Institute of Psychiatry and Maudsley Hospital. Clark professed to high rates of improvement from CBT but low availability of the therapy despite NICE guidelines now recommending it for several mental disorders.
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 and indeed eventually pay for itself by increasing productivity and reducing state benefits such as Disability Living Allowance and Incapacity Benefit (which had seen rising claims since their introduction by John Major's Conservative Party 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. [21] Layard names several others as having helped gain the initial political traction for the initiative – MP Ed Miliband, psychiatrist Louis Appleby (then National Director for Mental Health), David Halpern (psychologist), psychiatrist David Nutt, MP Alan Milburn (married to a psychiatrist) and eventually the PM Gordon Brown. [20]
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. [22] [23] This facilitated the development of IAPT initiatives, [24] 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. Some mental health professionals cast doubt on the claims early on. In the official publication of the British Psychological Society 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; [25] they were met with much agreement as well as angry criticism. [26] One researcher cited the UK initiative as the most impressive plan to disseminate stepped-care cognitive behaviour therapy. [27] 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.
General:
Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. Cognitive behavioral therapy is one of the most effective means of treatment for substance abuse and co-occurring mental health disorders. CBT focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include many issues and the treatment of many mental health conditions, including anxiety, substance use disorders, marital problems, ADHD, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.
Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy that is controversial within the psychological community. It was devised by Francine Shapiro in 1987 and originally designed to alleviate the distress associated with traumatic memories such as post-traumatic stress disorder (PTSD).
Peter Richard Grenville Layard, Baron Layard FBA is a British labour economist, programme director of the Centre for Economic Performance at the London School of Economics, and co-editor of the World Happiness Report.
Mental disorders are classified as a psychological condition marked primarily by sufficient disorganization of personality, mind, and emotions to seriously impair the normal psychological and often social functioning of the individual. Individuals diagnosed with certain mental disorders can be unable to function normally in society. Mental disorders may consist of several affective, behavioral, cognitive and perceptual components. The acknowledgement and understanding of mental health conditions has changed over time and across cultures. There are still variations in the definition, classification, and treatment of mental disorders.
The British Association for Behavioural and Cognitive Psychotherapies (BABCP) is a British-based multi-disciplinary interest group for people involved in the practice and theory of cognitive behaviour therapy.
Psycho-oncology is an interdisciplinary field at the intersection of physical, psychological, social, and behavioral aspects of the cancer experience for both patients and caregivers. Also known as psychiatric oncology or psychosocial oncology, researchers and practitioners in the field are concerned with aspects of individuals' experience with cancer beyond medical treatment, and across the cancer trajectory, including at diagnosis, during treatment, transitioning to and throughout survivorship, and approaching the end-of-life. Founded by Jimmie Holland in 1977 via the incorporation of a psychiatric service within the Memorial Sloan Kettering Cancer Center in New York, the field has expanded drastically since and is now universally recognized as an integral component of quality cancer care. Cancer centers in major academic medical centers across the country now uniformly incorporate a psycho-oncology service into their clinical care, and provide infrastructure to support research efforts to advance knowledge in the field.
In Scotland, a Clinical Associate is a shortened designation for a Clinical Associate in Applied Psychology (CAAP). A Clinical Associate is a specialist regulated mental health professional whose duties include assessing, formulating, and treating clients all within specified ranges of conditions and age. Clinical Associates work either in primary care adult mental health settings or in a range of setting working with children, young people, and their families.
Management of depression is the treatment of depression that may involve a number of different therapies: medications, behavior therapy, psychotherapy, and medical devices.
Mixed anxiety–depressive disorder (MADD) is a diagnostic category defining patients who have both anxiety and depressive symptoms of limited and equal intensity accompanied by at least some autonomic features. Autonomic features are involuntary physical symptoms usually caused by an overactive nervous system, such as panic attacks or intestinal distress. The World Health Organization's ICD-10 describes Mixed anxiety and depressive disorder: "...when symptoms of anxiety and depression are both present, but neither is clearly predominant, and neither type of symptom is present to the extent that justifies a diagnosis if considered separately. When both anxiety and depressive symptoms are present and severe enough to justify individual diagnoses, both diagnoses should be recorded and this category should not be used."
The National Collaborating Centre for Mental Health (NCCMH) is a collaboration between the Royal College of Psychiatrists and the Centre for Outcomes Research and Effectiveness at University College London (UCL). The NCCMH aims to promote the role of evidence synthesis in making informed judgments about healthcare policy. The NCCMH has a history of developing guidelines, conducting systematic reviews and developing implementation guidance for commissioners and service providers. Formed in 2001, on 1 April 2016 a new guideline development centre, the National Guideline Alliance, based at the Royal College of Obstetricians and Gynaecologists took over the clinical guideline programme that had been run by NCCMH.
Panic disorder is a mental and behavioral disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something terrible is going to happen. The maximum degree of symptoms occurs within minutes. There may be ongoing worries about having further attacks and avoidance of places where attacks have occurred in the past.
The primary care behavioral health (PCBH) consultation model is a psychological approach to population-based clinical health care that is simultaneously co-located, collaborative, and integrated within the primary care clinic. The goal of PCBH is to improve and promote overall health within the general population. This approach is important because approximately half of all patients in primary care present with psychiatric comorbidities, and 60% of psychiatric illness is treated in primary care.
PTSD or post-traumatic stress disorder, is a psychiatric disorder characterised by intrusive thoughts and memories, dreams or flashbacks of the event; avoidance of people, places and activities that remind the individual of the event; ongoing negative beliefs about oneself or the world, mood changes and persistent feelings of anger, guilt or fear; alterations in arousal such as increased irritability, angry outbursts, being hypervigilant, or having difficulty with concentration and sleep.
David Millar Clark, is a British psychologist.
Metacognitive therapy (MCT) is a psychotherapy focused on modifying metacognitive beliefs that perpetuate states of worry, rumination and attention fixation. It was created by Adrian Wells based on an information processing model by Wells and Gerald Matthews. It is supported by scientific evidence from a large number of studies.
Homework in psychotherapy is sometimes assigned to patients as part of their treatment. In this context, homework assignments are introduced to practice skills taught in therapy, encourage patients to apply the skills they learned in therapy to real life situations, and to improve on specific problems encountered in treatment. For example, a patient with deficits in social skills may learn and rehearse proper social skills in one treatment session, then be asked to complete homework assignments before the next session that apply those newly learned skills.
Adrian Wells, CPsychol, is a British clinical psychologist who is the creator of metacognitive therapy. He is Professor of Clinical and Experimental Psychopathology at the University of Manchester, U.K. and is also Professor II of Clinical Psychology at the Norwegian University of Science and Technology.
MindSpot Clinic (MindSpot) is Australia's first free national online mental health clinic which launched in December 2012. It provides screening assessments and internet-delivered cognitive behavioural therapy (ICBT) courses for Australians troubled by stress, worry, anxiety and depression.
Stefan G. Hofmann is a German-born clinical psychologist. He is the Alexander von Humboldt Professor and recipient of the LOEWE Spitzenprofessur for Translational Clinical Psychology at the Philipps University of Marburg in Germany examining Cognitive Behavioral Therapy, especially for anxiety disorders. Since 2012, he has been editor in chief of the journal Cognitive Therapy and Research
The Association for Psychological Therapies (APT) is a body providing recognition of excellence, training, resources, and accreditation to professionals working in Mental Health and related areas, mainly in the UK's National Health Service and Independent Health providers, but also in Canada and Australia.
<25>Scott, M.J (2018). "IAPT - The Need for Radical Reform". Journal of Health Psychology.</ref> <26>Scott, M.J (2021). "Ensuring IAPT Does what It Says On the Tin". British Journal of Clinical Psychology. 60 (1): 38–41. doi:10.1111/bjc.12264. PMC 7891596 . PMID 32803761.</ref> <27>Kellet, S (2021). "The costs and benefits of practised based evidence". British Journal of Clinical Psychology.</ref> <28>Davis, A (2020). "Predicting Patient Engagement In IAPT Service". Evidence-Based Mental Health. 23 (1): 8–14. doi:10.1136/ebmental-2019-300133. PMC 7034348 . PMID 32046987.</ref>