Two talking therapy pilot schemes aim to deliver accessible treatment programmes to those with mild to moderate mental health problems. But are they simply a catch-all solution for a wide range of conditions? Emma Dent reports
Health improvements that pay for themselves are surely the holy grail for any government exchequer. That was the enticing prospect laid out in June's Depression Reportfrom the London School of Economics' mental health policy group. It argued that expanding therapy services will not place an extra burden on health service funding because the cost of psychotherapy treatment would be covered by savings in incapacity benefit and lost tax receipts when the patient is able to return to work.
Although talking therapies are the single most in-demand treatment for people with severe and enduring mental illness, the focus of current debate has been the lack of accessibility of these treatments for people with mild to moderate mental health problems.
With 8.8 per cent of the general population experiencing anxiety and depression and 7.8 per cent having a major depressive disorder, there are huge numbers of people likely to benefit. But among patients visiting their GP with depression or anxiety, 92 per cent are offered medication alone, while psychological therapies will be suggested for just 8 per cent. Of these, only 1 per cent will be offered cognitive behavioural therapy, although there is an evidence base to support its use and it is comparatively quick and cheap.
The case for talking therapies as effective treatment for many generalised depression and anxiety disorders has been made for some time and was confirmed in National Institute for Health and Clinical Excellence guidelines published at the end of 2004. They have been shown to achieve improvement in 60 per cent of cases of major depressive disorder and 75 per cent of panic disorders.
With the number of people claiming incapacity benefit because of mental health problems higher than the total number of unemployment benefit claimants, there are stark consequences for the exchequer.
Lord Layard, who chairs the LSE group that produced the report, points out that the NICE guidelines for the treatment of mild to moderate mental health problems cannot be implemented because there are not enough therapists.
But it is estimated that some access to talking CBT, of which the short-term success rate is around 50 per cent, with less likelihood of relapse than other treatments, costs just£750.
Lord Layard believes that within five to 10 years 5,000 people could be trained as clinical psychologists, with a further 5,000 mental health nurses, social workers and occupational therapists trained over two years to deliver talking therapies full time.
The LSE report was the most recent in a body of work Lord Layard has produced on mental health topics, the first being last year's paper for the prime minister's strategy unit.
There is little doubt that his views have been heard in high places and, in May, health secretary Patricia Hewitt announced two innovative talking therapy pilot schemes, in Newham, east London, and Doncaster, south Yorkshire. The Newham scheme is now open; the Doncaster project is due to launch this month.
Ms Hewitt acknowledged the demand for talking therapies and proclaimed that the demonstration sites would herald the beginning of the end of the 'Prozac nation'. Those running both pilot schemes say they will be addressing huge need.
Setting one of them in Newham poses particular challenges. The borough is England's fourth most deprived area and has the third highest unemployment rate in London and the highest number of refugees in the capital. Demand for mental health services in the local population of 250,000 is 40 per cent above the national average.
'If we show the pilot can work here, it can work in any context,' says Ben Wright, clinical lead at the Newham site, and a consultant psychiatrist in the psychological therapies service run by East London and the City Mental Health trust, which will oversee the project.
It aims to deliver accessible and culturally appropriate therapy - vital in a borough as diverse as Newham, where 62 per cent of the population are from black and minority ethnic groups and 120 languages are spoken - to integrate therapy with existing services and demonstrate cost-effectiveness.
For the latter, timing is crucial. Each demonstration site will run for 15 months, be independently audited and be expected to provide information to support the wider introduction of the schemes in the 2006-07 spending review.
Taking the form of a psychological treatment centre, the Newham pilot, which opened in East Ham last week, will house eight therapists trained in CBT. It will also be home to an employment service with three employment coaches and social support from non-statutory provider Mental Health Matters. Existing services will be supplemented by an extra two and a half non-CBT therapists.
Varying levels of skills and experience, from newly qualified trainees upwards, have been acquired through the new therapists to match the needs of the patient to the skills of the therapist. Efforts have also been made to recruit staff who speak some of the minority languages commonly used in the borough, although translation services will also be needed.
'It has been shown that the most difficult cases go to the least qualified therapists; that makes no sense,' says Dr Wright. 'There will be cases available for every level of skill. They will be assigned to result in the most mutual benefit. This is not a randomised controlled trial - what we need is evidence of the pilot's effectiveness, not its efficiency.'
Referrals to the service will be made by 13 local GPs. An assessment will be carried at the client's home, GP surgery or the treatment centre. Services will be able to be accessed in GP surgeries as well as the treatment centre. All the therapists will report to and be supervised by the treatment centre to avoid them becoming isolated and so that training and development can be provided.
'Anyone referred to the service who is severely ill will be referred to secondary care services,' says Dr Wright. 'We expect many of the clients will be completely new to us, although they will be known to their GP, who will not have been able to refer them for this kind of treatment before.'
Supply and demand
Acknowledging that there is a danger that demand for the service could outstrip supply, Dr Wright doubts there will be a need for self-referrals or to advertise. The pilot will cover only a third of the borough and it is estimated it will see over 2,200 clients. 'If we are overwhelmed, then we will offer large group treatments, education about conditions and self-help treatments, and computerised CBT,' says Dr Wright.
In Doncaster, project director Heather Raistrick is also in no doubt that the area needs the services the scheme will provide.
As in Newham, the pilot is designed to build on existing mental health provision, through a partnership of local primary care trusts, secondary care provider Doncaster and South Humber Healthcare trust, voluntary and community groups and the local authority. Another crucial partner is the chamber of commerce, which will house the pilot, although most services will be delivered in GP surgeries and community settings. Pathways to Work, which offers tailor-made solutions to assist those with health problems back into work, will be housed alongside the pilot, as will employment advisers.
The pilot has funded 14 case managers and three CBT therapists to be added to the existing local provision of six case managers and six CBT therapists, and is due to begin later this month.
All case managers, who will have 200 clients each over the course of the 15-month scheme, have undergone intensive training in CBT interventions, while the therapists assigned to supervising the case managers have been trained accordingly.
Ms Raistrick stresses the extent of local need: 'There is high unemployment and high numbers - 21,000 - of local people on incapacity benefit. Of those, a quarter have mild to moderate mental health problems.'
She stresses that the pilot will not offer CBT as a one-size-fits-all option.
'We will deliver a high-volume, low-intensity approach, which will deliver access to CBT for many more patients than has been traditionally available.
'There will be a broad spectrum of mental health and supportive interventions available at every stage, including computerised CBT, short-term one-to-one interventions, group work and anxiety management. Choice is key.'
The extra capacity provided by the pilot should provide psychological therapies to 5,000 clients who are not receiving them now.
'The bulk of referrals will come from GPs and primary care. We hope to also get referrals from Pathways to Work,' adds Ms Raistrick. 'The stepped-care approach should prevent us from being overwhelmed, as we will have different thresholds in place and therapists in place at every step.'
Anticipated outcomes of the pilot include a reduction in prescribing and the issuing of sick notes, a reduction in inappropriate referrals to secondary care and an increase in the number of people returning to or staying in work.
The stepped-care approach common to both pilots is recommended by NICE and addresses managing need for mild problems at tier one
to the need for secondary care for severe problems at tier four.
This approach is being used in other areas, independent of the demonstration sites, by organisations looking to increase their access to talking therapies.
South West London and St George's Mental Health trust recently advertised for therapists to staff a primary care-based service commissioned by Sutton and Merton PCT. The existing service already follows a stepped-care approach and the new staff will enable it to be extended.
Trust director of psychology and psychotherapies Chris Gilliard says: 'We are expanding into an area where provision has historically been patchy.
'We also signpost to a range of services for people who need some sort of help but not a clinical intervention. Principally, the clients will have had no contact with mental health services before.'
Although there is broad support for the demonstration sites, concerns remain that they are being seen as a catch-all solution to a huge range of problems. The emphasis placed on the pilots' planned ability to get people back to work causes disquiet for some.
'There is some confusion over who can be helped with CBT,' says Mental Health Foundation chief executive Andrew McCulloch. 'People with mild to moderate problems may benefit from it but then there are the long-term sick who have complex needs and will need more than a CBT programme to get back to work.'
'There is too much expectation on the demonstration sites,' he cautions. 'My concern
is that if they do not result in enough of a reduction in people claiming incapacity benefit
they will only be regarded as a partial success and not rolled out.'
He adds that the NICE recommendations for the treatment of common mental health problems is the only guidance from the organisation that has had to be piloted in the service before spending on it is approved. 'You do not pilot the use of a new antidepressant. Why not just get on with it?' he says.
MIND chief executive Paul Farmer points out that the sites are aiming to demonstrate how large-scale implementation of talking therapies can be introduced effectively when existing provision is so patchy.
He adds that getting people back to work is not always a realistic outcome. 'This has to be about people being helped on the journey to recovery,' he says.
Back in Newham, Dr Wright denies that the pilot is purely designed to get patients off benefits but to help them get to wherever they want to be: work, being a homemaker or going
'It is about delivering services that make people able to be socially active when they may not have been able to leave the house before,' he says.