‘A broken leg gets treated in few hours. But a broken spirit will take months, and often won’t be treated at all’. It’s a haunting comparison often used by Richard Layard, and a theme picked up by the Prime Minister in her first major domestic policy intervention. The economic and social costs are almost as shocking as the psychological costs: estimated at more than £100 billion per annum, as the PM pointed out. Depression alone is the single greatest cause of years of working life lost.
But how, in a world of deeply constrained resources, can we do better?
The PM announced initiatives on children and young people’s mental health, prevention and resilience in schools and workplaces, increasing places of safety in the community – and a major expansion of clinically-assisted digital therapy. Right now, short of a major raid on Treasury, the latter is the only way that we can come close to addressing the Layard challenge, or indeed that of Paul Farmer, to expand the volume of quality treatment available.
There are several key elements to this digital push:
First, the introduction of online triage (and via the NHS non-emergency number, 111). Psychiatrists have long used clinically validated questionnaires that enable rapid diagnosis. Back in the 1960’s and 1970’s, when scales such as the early Langer 22-item mental health index was developed, there was widespread concern that people would not want to, or be able to, answer questions about their mental health (hence the predominance of more ‘somatic’ or physical symptom questions in the early scales, and even in their names, such as Goldberg’s 1972 ‘General Health Questionnaire’). Comparing answers on such questionnaires to the ‘gold-standard’ of direct personal assessments by experienced psychiatrists enabled their gradual refinement and the establishment of robust cut-offs indicating when an individual was likely to be suffering from a mental health condition. Further work led to the development of scales that were shorter (the GHQ was originally 60-items, followed by a 30-item and then 12-item scale with little loss of predictive power), and more able to diagnose specific conditions.
Last year, there were 32 million visits to the mental health pages on the NHS choices website. After nearly 50 years of research and development, it is about time such scales became available to help people self-diagnose and be guided towards appropriate help.
Second, there is now a substantial body of randomised controlled trials (RCTs) showing that clinically-assisted digital forms of psychological therapy appear to work as well as clinician only approaches. This programme will bring to the UK approaches that have worked elsewhere, and prompt the development of new approaches and platforms. Under National Institute for Health and Care Excellence (NICE) guidance, these will be rapidly evaluated through the Improving Access to Psychological Therapies (IAPT) programme, and the data that it gathers. Approaches that are confirmed to work at least as well as conventional treatments will be rapidly made available to the whole of the IAPT programme, while those that are less effective will be dropped.
This rich data should allow clinicians to identify which approaches work best for who. Digital platforms also make it easier to test variations. Could the addition of screening and support for those experiencing financial difficulties improve outcomes? Which other therapies, apart from Cognitive Behavioural Therapy (CBT), work better for some people and in what circumstances?
Digitally assisted approaches should also help address geographical black spots in access to particular therapies and increase patient choice. Meta-reviews suggest that involving patients in the choice of therapy improves satisfaction, completion rates, and clinical outcomes.
Third, digitally assisted approaches make it much easier to check in with patients after the treatment has finished. This enables clinicians to check the long-term relative efficacy of different treatments in a ‘real-world’ context (refining and improving them accordingly). Perhaps more importantly, it enables patients who are in need of ‘top-up’ treatment to receive it before further breakdown occurs.
The UK has much to be proud of in its pioneering IAPT programme, with other countries, such as Canada, increasingly looking to put something similar in place. I remember the Cabinet Office meeting we held that led to the launch of IAPT. A decade on, it’s time to give the programme a digitally empowered upgrade. There are not enough clinical psychologists in the UK to treat the around 13 million Britons wrestling with mental health issues. Digitally assisted approaches can enable clinical psychologists to support more people, with more sessions, and at a remarkably low-cost. More importantly, it offers the prospect of alleviating a great deal of suffering.