What's new in efforts to improve access to mental health care? In the United States, all eyes have been on the Affordable Care Act. But on the opposite side of the Atlantic, another government has undertaken an ambitious project to improve access to mental health care.
In 2008, the United Kingdom launched the Improving Access to Psychological Therapies (IAPT) program, a large-scale initiative to expand access to psychological therapy as a first-line treatment for depression and anxiety disorders. In the seven years since the program launched, some 6,000 new therapists have been trained and put to work in specialized treatment service centers across England. The centers are widespread and accessible; there are one or more new IAPT service centers in each of 211 "health regions."
The program is still relatively new, and it's not perfect. Critics complain that wait times to see an IAPT psychologist are often much too long, while the course of therapy offered is often too short for patients with more complex cases (The Lancet, 2015).
Supporters counter that IAPT has notably increased access to psychological services. Before the program began, fewer than 5 percent of people with anxiety or depression received evidence-based psychotherapy, says David M. Clark, PhD, an Oxford University psychologist who helped spearhead IAPT and is now its clinical advisor. Some 13.5 percent — about 760,000 people a year — now receive services through the IAPT program. While some are referred by physicians, patients can also make appointments themselves, Clark says.
Clark teamed up with labor economist Richard Layard, PhD, professor emeritus at the London School of Economics, to make the case for the IAPT program. In their book "Thrive: How Better Mental Health Care Transforms Lives and Saves Money," which will be released in the United States in September, they share the blueprint for how they did it.
One key to the program's success, they say, is a set of evidence-based clinical practice guidelines that spell out the best treatments for any given condition. In fact, those guidelines are one of the models that APA is looking toward as the organization undertakes the process of developing its own practice guidelines for mental health concerns. Establishing them will be a big step toward improving access to evidence-based psychological treatment in the United States, says Steven Hollon, PhD, a psychologist at Vanderbilt University and chair of the APA guidelines steering committee.
Certainly, there are major differences between the U.K.'s National Health Service and the U.S.'s patchwork of private insurers. But there are also important similarities, says Clark. Both systems emphasize medications for depression and anxiety, for example, even though evidence suggests psychological therapies are often as good or better, and very often longer-lasting.
From Clark's perspective, mental health is an issue that no country can afford to ignore. "Mental health has a vast impact on the extent to which society thrives. On a straightforward economic argument, it's a no-brainer," he says. "It is economic madness not to provide evidence-based psychological treatment."
A natural experiment
That economic argument is a strategic one. "I don't think the IAPT would have gotten off the ground if I'd just argued as a psychologist for the clinical benefit," he says. "We had to put the economic and clinical arguments together."
Those arguments are hard to deny. Clark points out that treating mental health problems leads to major savings in physical health-care costs. Depression and anxiety often occur in tandem with physical health problems, such as diabetes, heart disease or chronic pain. Treating physical conditions is considerably more costly when the patient has a psychological problem as well, Clark says.
"But we know — and much of the evidence comes from trials in the U.S. — that the cost of delivering the psychological treatment is covered fully by the savings you make in the physical health-care costs alone."
There's also a broader economic benefit to improving mental health, Clark says. People with untreated depression and anxiety are less likely to be fully employed. And those who are employed have higher rates of absenteeism, leading to reduced productivity and lost revenue. "Society benefits from treating people with mental health problems," he says.
At the heart of the IAPT program is a set of evidence-based guidelines produced by the U.K.'s National Institute for Health and Clinical Excellence (NICE), an interdisciplinary body that reviews the effectiveness of clinical procedures. The group has issued clinical guidelines for physical medicine for some time, but only began issuing guidelines for mental health disorders in 2004.
"In their guidelines, they made very clear that for depression, anxiety disorders, eating disorders and, more recently, personality disorders, evidence-based psychological therapies were among the first-line treatments," Clark says.
Another important factor, Clark says, is that patients often prefer psychotherapy: A meta-analysis of nearly three dozen studies found that 75 percent of patients prefer psychotherapy to medication (Journal of Clinical Psychiatry, 2013).
"We had a whole series of clear-cut recommendations for evidence-based psychological therapy, a clear public preference for those therapies — and very few people were getting them," Clark says. The IAPT aimed to change that.
Following the NICE guidelines, IAPT offers stepped care to many patients with mild to moderate depression or anxiety, he explains. In such cases, the first step is a low-intensity intervention such as guided self-help or computerized cognitive-behavioral therapy (CBT). While many people recover from this intervention, those who do not go on to a course of face-to-face therapy. Patients with more severe symptoms, however, go straight to psychological therapy, as recommended by the guidelines. And some patients who receive IAPT services also take medications, as prescribed by their family doctor. "IAPT is a partnership with primary care," Clark says.
The program is not without criticism, however. In a recent report in The Lancet, Julian Lousada, PhD, chair of the British Psychoanalytic Council, and colleagues argue that wait times to see an IAPT psychologist are often much too long, forcing patients to seek help from more expensive private-sector psychotherapists instead. The authors also argue that while IAPT focuses on anxiety and depression, many patients with enduring problems such as personality disorders or comorbid conditions are falling through the cracks (The Lancet, 2015).
Clark admits there's more work to be done. But he is optimistic about the program's successes so far. As an initial goal, the program set out to achieve a 50 percent recovery rate for depression and anxiety, in which a patient is considered recovered only if he or she drops below the clinical threshold for not just one, but both, conditions. So far, Clark says, the average recovery rate in the IAPT centers is 46 percent, while another 15 percent of people have shown "reliable improvement."
But recovery rates vary significantly from region to region. Many clinical regions exceed the 50 percent recovery target, and one large service boasts a better than 70 percent recovery rate, says Clark. Other areas are lagging. "One of the big things we're now starting to work on is whether we can help those services that have lower recovery rates move up to the same standard," Clark says.
What accounts for the differences? The explanations are illuminating, both for health-care providers and policymakers.
One important factor seems to be how well providers stick to using evidence-based treatments. Clark and his colleagues have found, for instance, that the services with lower recovery rates are more likely to give fewer than the recommended number of therapy sessions. "You'd never dream of giving half a hip operation, but it seems that people are happy to have half a course of psychotherapy given, and that's just not fair," he says.
Similarly, centers that emphasize the types of treatment recommended by the NICE guidelines have higher recovery rates than do centers that opt for treatments not endorsed by the guidelines. "In a sense, the IAPT has provided a natural experiment," Clark says. "When therapy deviates from the guidelines, patients suffer."
The U.S. angle
In 2010, APA decided the time was right to start developing its own rigorous, evidence-based guidelines for the treatment of mental health disorders and behavioral issues.
While the U.K.'s NICE guidelines offer a model we can learn from, guidelines for the U.S. health-care system will necessarily be different, says Daniel Kivlahan, PhD, national mental health program director for addictive disorders in the Veterans Health Administration and an associate professor at the University of Washington. Kivlahan is a member of the APA steering committee overseeing the development of clinical practice guidelines for mental health concerns, and is also involved in efforts to develop practice guidelines for the VA. Some medications approved in one country are not available in the other, for example, and therapy services might be delivered differently.
For the first phase of its effort, APA has appointed panels to review the literature and compile evidence-based guidelines for three initial topics. Draft guidelines for trauma/post-traumatic stress disorder should be finalized later this year, with guidelines for depression and obesity scheduled to be finished in 2016. The panels are made up of experts from a variety of disciplines, including psychology and medicine. These panels will consider all possible treatments, including psychological therapies, medications, exercise and more, says Hollon. "Whatever is in the individual's — and the public's — best interest is what we want to emphasize, no matter where the chips fall for any given profession."
Not all psychologists have lauded the effort. Some have expressed concern that clinical practice guidelines could eliminate their favorite schools of psychotherapy — favoring methods such as cognitive-behavioral therapy, say, over interpersonal psychotherapy or psychodynamic therapy, for instance. But those fears are unfounded, says Boston University psychologist David H. Barlow, PhD. "What the NICE guidelines show is that there are approaches from all schools that have achieved the distinction of being evidence-based." Emphasizing the strong evidence base for psychological therapies, he adds, "can only help psychologists."
Show me the data
Clinical guidelines are clearly an important ingredient as the U.S. health-care system moves further toward evidence-based practice. But equally important, experts say, is an emphasis on tracking the effectiveness of treatments and interventions.
"Before the program, we weren't very good at measuring the clinical outcomes of people in routine psychological therapy services," Clark says. When IAPT was launched, just 38 percent of people receiving psychological services were given standardized measures at the beginning and end of therapy. Post-IAPT, he says, it's up to 97 percent.
Having that data allows decision-makers to see exactly what works and what doesn't. "Politicians get lots of people arguing you should do this or that, but unless you can show that it works, they're not going to stick with you," Clark says. Thanks to solid data, all of the U.K.'s major political parties have pledged their support for the IAPT program, he adds.
"The major lesson out of the IAPT initiative is that measurement is fundamental, both on the front end and to inform care going forward," says Kivlahan. "It's important to be able to track whether we're progressing toward the priority goals. If you can't measure it, you can't change it."
And change, ultimately, is where many experts hope mental health care is headed. "Prospects really have improved a lot for people in treatment for mental health problems," says Clark. "The shame is that in both the U.K. and the U.S., the majority of the public isn't benefiting from those treatments."
"There's always resistance to change. Any new idea has to gather steam and reach a tipping point," Barlow adds. "But I think evidence-based practice has clearly reached a tipping point and we're sliding down the other side. It's an idea whose time has come."
Kirsten Weir is a journalist in Minneapolis.