Is the roll-out of talking therapies fast enough?

Using cognitive behavioural therapy and evidence-based therapies, a programme known as IAPT is filling a void in mental health provision, writes Andrew Mickel

New Horizons, the government’s replacement for the national service framework on mental health, entered consultation at the end of July. It has two main ambitions: to improve the mental health and well-being of the population, and to improve the quality and accessibility of mental health services.

One service is already trying to tackle both these aims for the 15% of the population who have depression or anxiety disorder. The £173m Improving Access to Psychological Therapies (IAPT) programme meets Nice guidance in providing cognitive behavioural therapy and other evidence-based therapies, and is available in 35 primary care trusts.

Moreover, it fills a gap in mental health provision. “Availability is variable and to some extent dependent upon local services and where you live,” says Hugh Griffiths, chair of the expert reference group for IAPT and the deputy national clinical director for mental health in the Department for Health. “In which other branch of medicine would that be acceptable? IAPT is about making sure we address that.”

75,000 referrals

For a service that started with only two pilot sites in 2006, IAPT is working with a lot of people. In the first six months there were 75,000 referrals, while more than 43,000 people have entered IAPT services, with 13,000 so far completing treatment.

A typical user will be referred by their GP, Jobcentre Plus or by themselves. After an initial assessment, they could expect to start guided self-help with a low-intensity therapist. Traditional cognitive behavioural therapy or interpersonal or couples therapy would be undertaken by a high-intensity therapist on referral. (The low- and high-intensity tags refer to the level of training for the therapist rather than the services provided.) If someone has more severe problems they can be referred to other mental health services.

Helen Watson is a high-intensity trainee in Stoke, where 18 low-intensity and eight high-intensity therapists serve a population of 250,000. Previously a graduate mental health worker in Doncaster, she became an IAPT low-intensity therapist when the area became one of two demonstration sites.

She says most people only need the help of a low-intensity professional. “As a graduate worker I was based at a GP’s surgery, and we did computerised CBT at another site,” says Watson. “When we switched to low-intensity work we started working with more surgeries and had larger caseloads, and started doing work over the phone as well.”

Caseload

As a low-intensity worker, Watson typically had a caseload of about 80. An average week consisted of 10 face-to-face appointments and 25 follow-up phone sessions. “The transition from face-to-face to telephone was tricky,” she says. “People think it’s not as good over the phone but that’s not necessarily the view of the people doing it.”

Delivering low-intensity services to those with depression in order to return people to work is an oft-flagged component of IAPT, and the Department of Health does say that the key interface for IAPT services is in working with local employment services.

But it is important not to overplay the role of work in IAPT. Watson says she is under no pressure to return people to work.

Richard Webb, co-chair of the Adass mental health network, adds: “A strength of IAPT is that local areas can develop their own priorities according to local requirements. In Telford and Wrekin the IAPT programme will include a focus on older people and people with long-term conditions – in this area, we know that only about 4% of over-65s are referred to primary care mental health services.”

Impressive progress

Despite this, the way that IAPT is being rolled out – starting in a few areas and focusing on people of working age, with side projects targeting difficult-to-reach communities – means that some groups will have to wait longer to access them.

Still, the progress that IAPT has made is impressive for a programme of its scale. More than 800 trainees are supervised by 500 experienced psychological therapy staff, and that number will climb in the autumn when a further 80 PCTs establish services.

Despite the successes of the programme, it is unclear what will happen to IAPT after 2011. “The £170m in year three is the commitment from the last comprehensive spending review,” Griffiths says. “We just don’t know what additional money there could be from year three.”

CASE STUDY

Antony Lane: Diagnosed with depression

“Therapist got to heart of what affected me”

Antony Lane had worked in council customer services in Stoke for 18 years, but in April 2008 he took time off work with severe stress, which was then diagnosed as depression.

“I had been sitting at home for the best part of three months and couldn’t focus as a normal person,” he says. “I couldn’t do the housework or the dishes, or focus on a book. I realised that I had to speak to someone.”

After a period on medication, he asked his GP about the local IAPT service, which provided six sessions of guided self-help.

Fired from job

Coincidentally, the first session fell the day after he was fired from his job. “I went into the meeting knowing that progress had to come from me, but I needed someone to say, ‘this is what you have to do’. It sounds silly that I couldn’t do it myself but my mind wasn’t working in the right way.

“[The therapist] had a workbook to go through. Some ideas were almost like an action plan. He had tried to get to the bottom of what I was feeling. He came up with some ideas to help me focus on a step-by-step basis.”

Despite using the service only briefly and mostly by phone – something that Lane says was his choice – focusing on what was important to get his life moving again was what he needed. “It was ideal for me,” he says. “They weren’t giving away your life secrets but getting to the heart of what was affecting me.”

Lane is now planning to start an online shop for war-gaming.

This article is published in the 13 August 2009 edition of Community Care under the headline “Meeting the Horizon”