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Psychological interventions are effective for many psychiatric disorders. In particular, cognitive behavioural therapy (CBT) is rigorously evidence based. The Canadian Network for Mood and Anxiety Treatments (CANMAT) depression guidelines state that CBT is as effective for mild and moderate depression as antidepressant medications, and combined psychopharmacology and CBT is superior to either modality alone.1 New research shows CBT can help cancer patients endure chemotherapy,2 assist the obese in weight management,3 and even help return patients with depression to full-time employment.4 For major mental illnesses, CBT is very effective, with low numbers needed to treat (for generalized anxiety disorder, posttraumatic stress disorder [PTSD], and depression: 2.3, 1.7, and 4.4, respectively5). At the same time, it must be acknowledged that it is not the only effective from of psychotherapy and that there is emerging evidence of decreasing effectiveness in more recent compared to earlier studies.6
CBT and other evidence-based psychotherapies require a major investment of resources and time. Thus, in public health care systems like Canada’s, these psychotherapies have limited availability.7,8 In this journal, Dezetter et al.9 surveyed nearly 1300 attendees at Quebec primary care clinics, finding unmet mental health needs in 40% of participants, including psychotherapy (in part because of a perceived inability to pay); Hadjipavlou et al.10 surveyed British Columbia psychiatrists, finding confidence in their psychotherapy efficacy but few patients are served because of time constraints.
Not surprisingly, then, the lack of access has promoted calls for change. In its “Changing Directions, Changing Lives: The Mental Health Strategy for Canada,” the Mental Health Commission of Canada focused on access, stating that “services for which we know people are waiting too long, if they can get it at all, are psychotherapies and clinical counseling,”8(p45) recommending an “increase to the availability and coordination of mental health services in the community.”8(p44) More recently, in a major report, Quebec’s L’Institut National d’Excellence en Santé et en Services Sociaux (INESSS), which advises evidence-based health policy in that province, called for greater access to psychotherapies for people with depression and anxiety.11
But how? In this article, which offers a perspective rather than a systematic review, we consider several options, including increasing the supply of psychiatrists and expanding the range of publicly funded services and providers. We also look abroad for answers, in particular to the United Kingdom and Australia, where recent efforts have increased access to evidence-based therapies. This article will show that—from Liverpool, England, to Liverpool, New South Wales—these countries experiment with ideas that are relevant here in their applicability.
One of the options for improving access to psychotherapy within a publicly funded system is to increase the number of psychiatrists. This assumes that more psychiatrists automatically means better access. At the same time, dominant cultural perceptions of “seeing a psychiatrist” for psychotherapy involve weekly individual hourly sessions. With 4000 psychiatrists currently in Canada, even if each performed 40 hours per week of psychotherapy, that model would provide ongoing care for 160,000 Canadians—a far smaller number than the estimated 6 million Canadians annually who experience some kind of mental illness. And the opportunity costs of such provision are the deprivation of people with schizophrenia and bipolar disorder of the specialized diagnostic and pharmacological management skills of psychiatrists.
Furthermore, recent evidence has cast doubt on this simple solution. Data from Ontario, home to one-third of the Canadian population, reveal that while the number of psychiatrists per 100,000 population varies profoundly from region to region, with supply in major urban centres well in excess of the recommended number by the Canadian Psychiatric Association, access does not improve in parallel.12,13
Since 2008, the National Health Service (NHS) has experimented with psychological interventions free to patients at the point of use and publicly funded; currently, over 500,000 receive treatment each year.
The origin of the program is a conversation.14 In 2003, at an afternoon tea, economist Richard Layard started speaking to the man standing next to him who he did not know, psychologist David Clark. Layard asked Clark if he knew much about mental illness. Clark did and noted the effectiveness of CBT for depression and anxiety but its lack of availability. Up to that point, Layard had largely focused his academic work on unemployment but was aware that mental health problems have a strong influence on people’s well-being; Clark, a noted therapist, had not written much on public policy. Layard and Clark agreed to team up and champion widely available CBT, with 2 arguments reflecting their 2 perspectives: the therapy is clinically and economically effective.
The improving access to psychological therapies (IAPT) model has 3 basic features.15 Care is stepped, meaning that people who are more ill get more treatment and higher levels of expertise as needed. Most people begin with “wellness” experts who provide information, including for self-help; these experts are trained therapists (obviously not psychiatrists). People with severe anxiety and depression, all people with PTSD, and those with milder symptoms who do not recover with the “wellness” experts are referred for the higher intensity treatments. Therapies are evidence based, including but not limited to CBT. Also, people can refer themselves to the program. About 40% have a single session. The majority, then, receive a course of therapy involving at least 2 sessions; in 2015, over 500,000 people were treated this way.15
IAPT reflects a strong investment and refocusing by the NHS. Originally, it started with 2 sites, Doncaster and Newham, offering CBT; IAPT has dramatically expanded in recent years. It is available in all areas of England; some 6000 therapists have been trained since 2008.15 To aid quality care, data are collected at each patient interaction. This allows IAPT to achieve unprecedentedly high levels of data completeness for clinical outcomes. Nationally, 97% of people who have had a course of treatment have pre- and posttreatment measures of the severity of their anxiety and depression symptoms. Around 2 million people have completed care. The initiative is, in the words of an NHS therapist, “the biggest expansion of mental health services anywhere in the world, ever.”14 It is also an extraordinary exercise in public transparency as the outcomes achieved by IAPT services in all 211 of the English Health regions (clinical commissioning groups [CCGs]) can be viewed on a public website (http://fingertips.phe.org.uk/profile-group/mental-health/profile/common-mental-disorders).
Has it worked? For those completing the program, the reliable recovery rate is now 43%, with over 60% showing improvement.16 (A case is defined as a recovery when a person improves through treatment from having clinical depression and/or anxiety to falling below the cut-off scores on both scales.) Results, however, are not homogeneous; a quarter of the programs in England had already exceeded the national target of 50% recovery by 2014, and some were reporting consistent recovery rates of over 60%.15 Of note, these rates are based on naturalistic but measurement-based outcome data on psychological treatments of millions of people; Canada is entirely lacking in national outcome data in this regard.
Studies have been conducted on subpopulations, including the elderly and the medically ill. IAPT has been shown to be clinically effective for the elderly, although older people tend to use the service less (just 4% in the Prina et al.17 study of the Eastern region). For people with chronic medical conditions, de Lusignan et al.18 showed that treatment with IAPT results in fewer emergency department (ED) visits and better treatment adherence; a separate study, also with de Lusignan as the lead author, replicated the ED visit reduction finding, and people were more likely to be prescribed antidepressants.19 Wroe et al.20 considered patients with diabetes, showing significant improvements in both physical and psychological measures post-IAPT. In a general medical practice that was studied, cost analysis compared people who had completed full treatment and partial treatment to those who did not do the therapy: expenditures fell by £1050 (full treatment) and £500 (partial treatment).21(p118)
A core justification for IAPT is that by government investing in people with mental illness, they will be more likely to return to the workforce and thus leave government support. Originally, it was estimated that employment status would increase by 4% (enough to offset program costs); in fact, it increased by 5%.22
Critics, particularly in the psychoanalytic community, note that IAPT does not focus on certain problems, such as personality disorders and medically unexplained conditions, and that such complicated problems demand more than short-term therapies.23
The criticism may be addressed as IAPT enters a new, expanded phase. Among the goals: reaching a greater number of people; targeting youth, particularly those with anxiety issues; offering a wider variety of evidence-based therapies (including interpersonal therapy and brief dynamic interpersonal therapy); and targeting people with long-term physical health problems (diabetes, cardiovascular disease, chronic obstructive pulmonary disease, etc.) in addition to anxiety and depression.
Has IAPT lived up to Layard and Clark’s original goals of clinical and economic effectiveness? Given that it boasts a robust recovery rate and increased employment, the answer is yes, although the unevenness of care delivery remains problematic, and the reality is that, as with all mental health treatments, there are people who do not respond or whose clinical states worsen.
In recent years, like the United Kingdom, Australia has looked to expand access to psychological services. Given the geographic issues—a population covering, literally, a continent—the core idea has been innovative: to better use technology in care delivery. This experiment has taken different forms, but the most interesting is the attempt to offer CBT through the Internet (iCBT). The contrast with the United Kingdom is more than simply bricks-and-mortar versus the World Wide Web; IAPT is a national government effort, with standardized care and data collection, while Australia offers a different type of public policy experiment consisting of many smaller efforts with a common means, using the Internet.
Of course, patients face more than geographic barriers in receiving traditional CBT—physical limitations (like pain) and/or personal obligations (e.g., family, career, academic). And CBT would seem like a natural fit for the Internet given its defined modules and reliance on homework and exercises.
We focus on two experiments:
MoodGYM offers iCBT free at the point of use. The website is popular; it has even been featured in the New York Times.24 In all, some 850,000 people have registered in MoodGYM around the world; the program has been translated into Finnish, Dutch, Norwegian, and Chinese. With 5 modules, MoodGym uses characters and situations to help people identify thought patterns and teach basic CBT concepts. So, as an example, the user is faced with a predicament—“It’s raining, your car breaks down, and you miss meeting up with your friends.… How do you feel? What are your thoughts?” The user then picks a response described by 1 of 3 characters. Elle, for example, notes, “This is the worst thing to happen.” The narrator explains, “It’s not the event that causes the depression—it is your interpretation of the event.”
THIS WAY UP Clinic, created through a university-hospital partnership, also offers iCBT—although the therapy is guided by psychologists who work directly with users. The e-clinic offers a number of courses, including Worry (for generalized anxiety disorder). THIS WAY UP Clinic takes full advantage of the Internet: an online calendar provides (email) reminders, progress reports are emailed to referring clinicians, and the graphically pleasing site uses comic book–style lessons, explaining key concepts in story form. In lesson 1 on “The Diagnosis” in the depression course, for example, we are introduced to “a 32 year old woman called Jess” who recounts her struggles with low mood. She notes, “My boss was always on my case.” This caption is accompanied with a picture of Jess being criticized by her boss. Later, she reports, “Life had lost its colour”—with a picture of her sitting on a park bench but with the colours blanched out. Again, interactively, the user works through scenarios, learning about basic CBT concepts.
While the applications of iCBT vary, these experiments have benefited from the involvement of the federal government. MoodGYM, for example, received $390,000 AUS in federal grants.25 In 2012, Sydney launched an e-Health Strategy with a major investment in iCBT.26 Mark Butler, then minister of Mental Health and Ageing, announced, “This reform agenda gives us an opportunity and presents us with a challenge: to remain alert and alive to innovative ways to further improve our mental health system. Online mental health services offer such an approach—both as an alternative, and as an adjunct, to face-to-face mental health care.”26(p2) Encouraged by policy and funding, iCBT has moved beyond depression and anxiety courses; MindSpot Clinic (similar to THIS WAY UP with therapist-guided care) offers courses for gastrointestinal pain, for example.
Is there evidence that iCBT works? One meta-analysis evaluated the effect size of 19 Internet- or computer-based CBT trials for anxiety, finding that iCBT patients had fewer symptoms and had moderate to large effect sizes in all clinical measures compared with placebo or waitlisted assignments, comparable to in-person CBT.27 In another meta-analysis of 23 computer-aided psychotherapy randomized controlled trials (RCTs) on anxiety disorders, researchers found a similar result: a large effect size (compared to controls) and comparable results with traditional CBT.28 In a third meta-analysis of 12 studies of iCBT for depression and anxiety symptoms, a large effect size was demonstrated (compared to controls).29 And other studies have shown evidence that iCBT works for other disorders.30 That said, the evidence favours well-designed, therapist-guided iCBT over computerized self-help programs, which seem to be plagued by high dropout rates.31,32
Has the real-world experience replicated the literature results? THIS WAY UP Clinic claims strong results: they boast a success rate of 75% for course completion and a 90% satisfaction rate.33 MindSpot Clinic, in a review of 1471 course completers, reports moderate to large effect sizes.34 For further data, see Table 1.35 But that is not quite to say that all Australian experiments have been a success. MoodGYM’s dropout rate remains high.36 (To address this adherence problem, many programs are now therapist guided.) Also, rural usage of mental health services trails urban centres.37
But like in the United Kingdom, Australia has found a way to increase access—a nontraditional way.
Psychological interventions are effective; they are an important part of the treatment of several common mental illnesses. In the Canadian context, however, psychotherapies are also difficult to access, beyond the financial and geographic reach of many patients.
Looking abroad, there are public policy experiments of interest. Both the United Kingdom and Australia have attempted to address limited access to psychological interventions, although their approaches are fundamentally different. In Britain, IAPT is built on stepped care, allowing people to receive CBT quickly and on a self-referral basis. It also requires the recruitment and training of a cadre of nonmedical clinicians of various disciplines and levels of expertise to match skills with patient needs. In Australia, the federal government has also invested in e-therapies, using technology to bridge the access gap, particularly relevant in a nation with rural populations spread over great distances (geographically different from our country, but with practical similarities in terms of underserviced rural need). Studies suggest success with both approaches.
And while it is possible to start experimentation on a small scale initially (an IAPT-inspired project, for example, is under way in Melbourne) or in a multisite action research project like the Mental Health Commission of Canada’s At Home/Chez Soi, either approach would ultimately require more funding of mental health services to translate into better access for all Canadians. Canadian Medical Association Journal Deputy Editor Kristen Patrick wrote that depression is the Cinderella of diseases—that is, like the fairy-tale princess, neglected compared to its physical health “step-sisters.”38 The problem with this analysis is its narrowness: all mental illnesses have been historically neglected. Funding more psychological interventions would make a material difference in people’s lives: for those with primary mental illnesses (like mood and anxiety disorders) but also those struggling with the psychological implications of physical health issues (such as cardiac and pulmonary diseases).
Moving forward, the federal and provincial governments would be well advised to increase funding for mental health, as the Mental Health Commission of Canada recommends (9% of health spending by 2022, up from 7% in 2012).8 Who delivers such publicly funded services—including nonmedical health professionals—and how they are delivered—leveraging the power of technology—are critical questions for planners and funders. There will never be enough psychiatrists alone to address the need, nor should there be.
The authors gratefully acknowledge the contributions of Professor David Clark of the University of Oxford, who provided both thoughtful comments on an earlier draft of this paper as well as updated data from the Improving Access to Psychological Treatments initiative.
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.