improving access to psychological therapy
The Oxford Centre for Anxiety Disorders and Trauma (OxCADAT), led by Professors David M Clark and Anke Ehlers, aims to improve the understanding and treatment of anxiety and stress-related disorders. Past successes include developing specialised forms of cognitive therapy that are now recommended by NICE as first line treatments for Panic Disorder, Post-Traumatic Stress Disorder (PTSD) and Social Anxiety Disorder. The group has been instrumental in advising the government on mental health issues and policies. Working with Professor Richard Layard from the London School Economics, Professor Clark successfully lobbied the government to create the English Improving Access to Psychological Therapies (IAPT) initiative and has been the National Clinical & Informatics Advisor for the programme since its initial roll-out in 2008.
Improving Access to Psychological Therapies
The English Improving Access to Psychological Therapies (IAPT) programme was created to address a health inequality. Anxiety disorders and depression are the most common mental health problems but before the start of the IAPT programme less than 5% of people in the community with such conditions were receiving a NICE recommended psychological therapy. To address this problem, the NHS has trained a new cohort of psychological therapists (currently around 10,000) and deployed them in new psychological therapy services that focus on the treatment of anxiety disorders, depression and post-traumatic stress. A unique feature of IAPT is its public transparency. The outcomes of everyone who receives a course of treatment are monitored and NHS Digital regularly publishes the outcomes of each IAPT service. Much has been learned from this exercise and, as a consequence, the services have been able to innovate and further improve their outcomes since the start of the programme. Currently, around 1.2 million people are seen for an initial assessment and advice in IAPT each year. Around 670,000 go on to have a course of treatment. A detailed account of the development of IAPT is available here.
The work of Professor Clark and his research group has underpinned substantial parts of the impact of IAPT. His pioneering work in developing and evaluating a community psychological therapy service for victims of the 1998 Omagh bomb demonstrated that the session-by-session outcome monitoring system that is so successfully used in IAPT was viable. The group’s analyses of IAPT data have identified optimal ways of organizing IAPT services and have been incorporated into NHS England’s operational manual for the programme. Partly because of this learning, the outcomes of IAPT services have substantially improved. Initially, 37% of treated patients fully recovered from anxiety and depression but the recovery rate is now consistently over 50% with approximately 7 in every 10 patients showing marked improvement. The NICE recommended panic disorder, social anxiety disorder and post-traumatic disorder treatments developed by the OxCADAT team are all included in the training curricula for IAPT therapists. In 2014 Layard and Clark published a popular book (Thrive: The power of psychological therapies) which outlined the combined economic and clinical arguments for IAPT and proposed the creation of an extension of the programme (IAPT-LTC) that would bring together the psychological and physical health care of people who are anxious and/or depressed and also have a long-term physical health problem such as diabetes, cardiovascular disease, or chronic obstructive pulmonary disease. The arguments were accepted by the Treasury and NHS England. IAPT-LTC services have now been created in many areas of the country. Initial evaluations show that they achieve excellent clinical outcomes while also helping the NHS to make valuable savings in physical healthcare costs.
The success of IAPT has attracted considerable international attention. An editorial in Nature described the programme as “world beating” and an approving feature article in the New York Times (24th July, 2017) described it as “the world’s most ambitious effort to treat depression, anxiety and other common mental illnesses”. An independent report in 2018, commissioned by the Ontario (Canada) Department of Health, concluded that IAPT was the world’s most successful attempt to increase public access to evidence-based psychological therapies for mental health problems. Professor Clark has advised health commissioners, politicians, and clinicians in other countries. Several have now started IAPT-like services including Norway where the programme is called “Prompt Mental Health Care”, Australia (“New Access” ), Ontario (“Structured Psychotherapy Programme” ), Finland (“Therapies to the Frontlines”) and Israel.
Responding to COVID-19: Adapting services and providing resources
The pandemic posed additional challenges to ensuring public access to psychological therapies. Professor Clark and the OxCADAT group helped NHS England and IAPT services to adapt to COVID-19 and prepare to deal with the mental health consequences. The team have created a wide range of resources to help therapists deliver therapy remotely during the pandemic. Most are available through a special COVID-19 Resources section in OxCADAT’s free therapist resources website, which is now being used by therapists in 139 countries. Recorded lectures on IAPT and its history are also available.