Improving access to psychological therapies: a challenge for the whole NHS?

Dr Ian McPherson, director of the National Institute for Mental Health in England (NIMHE), welcomes the recent major investment in psychological therapies but highlights the wider implications this raises for the NHS

Health secretary Alan Johnson’s announcement of a £170 million expansion of psychological therapies to provide better support for people with common mental health problems such as anxiety and depression is a landmark decision which will enable major developments in an area of mental health that has not previously had much attention, despite the strong evidence base for psychological therapies and the demand from people to have access to these.

The move came as part of the comprehensive spending review details announced on 9 October and will enable the implementation of the National Institute for Clinical Excellence (NICE) guidelines on treatment for depression and anxiety that recommend a stepped care model and access to evidence based therapies, particularly, but not solely, cognitive behavioural therapy (CBT).

Building on two NIMHE improving access to psychological therapy (IAPT) demonstration projects in Doncaster and Newham, the investment will next year roll out enhanced psychological therapy services in at least 20 new areas before increasing services to cover the whole country over the next few years.

By 2010/11, the NHS will spend £170m per year on psychological therapies, with more than £30m in 2008/09 and more than £100m in 2009/10. Over the next three years, this investment IAPT will mean:

900,000 more people treated for depression and anxiety

3,600 more newly trained psychological therapists giving evidence-based treatment , and

all GP practices having access to psychological therapies as the programme rolls out.

It will also bring down the average waiting time for psychological treatments which currently can be 18 months in some areas to a few weeks.

While this will be a great advance, it needs to be accompanied by a change in attitude to mental health problems and a challenge to the mind body dualism between mental and physical health that still pervades the NHS as well as failing to connect physical and mental well being with wider social factors.

People with common mental health problems, sometimes referred to pejoratively in the past as the “worried well” are more commonly “worried sick” as they can be significantly disabled by their problems as well as frustrated by their inability to access treatment, as they are normally not seen to meet the criteria for specialist mental health services. In reality 90% of people with mental health problems are treated in primary care without referral to specialist service resulting in one third of all GP consultations (ie 90 million consultations per year). Many people respond well to existing support at this level, but for those who need more, GP’s have traditionally found themselves caught in the bind of being unable to access specialist support, while at the same time being criticised for writing too many prescriptions and ” sick notes”.

This has consequences not just for patients and GPs but for society as a whole, as.3 in 10 working age people have sick leave in any one year due to mental health problems, resulting in 91 million lost working days, and over 1 million of these people end up on long term sick leave receiving incapacity benefit. Of particular concern is that the proportion returning to employment, after having been on incapacity benefit for 12 months or more is less than 5%. This means that if you have been on incapacity benefit for a mental health problem for more than one year you are more likely to die than return to work.

The interface between mental health and physical health problems is also often not recognized despite the fact that strong associations exist between depression and ischaemic heart disease, diabetes and COPD and that better management pf psychological factors can improve outcomes and the impact of disease in these areas. This is important not just for the quality of life but can be related to morbidity. 33% of people who have a heart attack develop depression but this group has a three times higher risk of dying in the following year, compared to non depressed people who have had a heart attack.

A further challenge to the healthcare system and getting better use of resources comes from the fact that across medical specialisms approximately 50% of people referred for outpatient investigations for physical health problems will have no identified underlying physical condition. For some people with medically unexplained symptoms this will be a one off occurrence, but for a significant proportion there is a risk that they get into a loop of referral between medical specialisms trying to find a physical basis for distressing symptoms which are actually reflecting underlying psychological factors and would be responsive to psychological interventions. This is not only a source of distress to the patients. It also means that acute healthcare resources that are often overstretched are not being effectively utilised.

The expansion of psychological treatment in primary care gives the opportunity to tackle all of these issues, but change in this area is needed not only in services but in attitudes. Despite their prevalence, people are often still reluctant to acknowledge that they are experiencing mental health problems at an early stage when they are likely to respond more readily because of the stigma associated with this and fear about the potential reaction from others, particularly employers. This is a challenge to all of us, not just those who work in mental health. To address this we need to move away from the view that mental health problems are something unusual that affect other people and recognise that they are very common and can affect any of us often in conjunction with physical health problems with a significant impact on our potential for employment and long term well being if not properly treated. This in turn may encourage us to work towards commissioning and providing the type of services and support that we would want for our family, our friends and ourselves.

NIMHE is part of the Care Services Improvement Partnership (CSIP). For more information about NIMHE www.nimhe.csip.org.uk and about the Improving Access to Psychological Therapies Programme see www.mhcoice.org.uk

E: ian.mcpherson@csip.org.uk

“if you have been on incapacity benefit for a mental health problem for more than one year you are more likely to die than return to work”

“people are often still reluctant to acknowledge that they are experiencing mental health problems at an early stage when they are likely to respond more readily because of the stigma associated with this”

“we need to move away from the view that mental health problems are something unusual that affect other people and recognise that they are very common and can affect any of us”