e latest psychotherapy transforms lives http://www.newscientist.com/article/mg22329770.200-know-this-the-latest-psychotherapy-transforms-lives.html

19 Jul

Economist Richard Layard and
psychologist David Clark champion
evidence-based therapies for depression
and anxiety. They tell how
their mission has just begun

Your book is about the mental health
initiative you two fought to
start. Who is the book for?

Richard Layard: Everyone. We hope it will
be a bestseller. David
Clark: We want people to realise where
science has got us to: people
whose lives might otherwise be ruined by
long-term mental health
problems can benefit from the latest
psychological treatments, and
many can have their lives transformed. If
you get treatment in your
20s and 30s, that means you’ve got 50
years of a very different
life.

How big a problem is the undertreatment of
mental illness?

RL: In rich countries one in five people
suffer a mental illness,
mostly depression or anxiety disorders.
Mental illness accounts for
38 per cent of all illness and even more for
people of working age.
Yet in most rich countries it gets under 10
per cent of healthcare
expenditure.

Coming from outside psychology, as an
economist, I was shocked.
Throughout the rich world, less than one-third of people with common
mental disorders are in treatment; for
common physical illnesses
like diabetes or cardiovascular problems,
it’s over 90 per cent.
This difference is an outrage. There are
people who have problems,
here and now, who could be treated and
are not being treated.

Why don’t people get treatment?

DC: Part of it is because health authorities
and doctors still do
not realise how powerful and cost-effective
the treatments are.
There’s also a lot of stigma about mental
health, which makes people
with mental illness less likely to seek
treatment. That is probably
made even worse because many don’t
know that there are effective
treatments waiting for them. These are
problems we set out to
address with the UK initiative we proposed,
Improving Access to
Psychological Therapies (IAPT). In the last
30 years there have been
major advancements in psychological
treatment, but they largely have
not been acted on in clinical practice.

Why has clinical practice lagged behind?

DC: There are lots of reasons. Among them,
there’s this very
unfortunate term “talking therapies”.
Everyone hears that and
thinks: “Oh, it’s just like having a chat with
someone who’s nice.”
People think it would be a nice thing to
have, but that it can’t be
very effective.

Of course, these therapies aren’t like that.
They are based on
science, they are tailored to and differ
between conditions, and
they have evolved enormously on the basis
of research about the
underlying psychological processes.

What are the consequences of
undertreatment?

RL: Among people who are least satisfied
with their lives, the
biggest cause is poor mental health. These
problems affect people in
every social class and have huge costs.
They also cause low
effectiveness at work, family break-up,
crime and a host of other
problems.

The programme started in England in 2008.
Six years on, has it made
a difference?

DC: Last year more than 700,000 people
were seen through IAPT
services, most of whom would not
otherwise get any psychological
therapy. In services with experienced staff,
about two-thirds of
people who receive a course of treatment
show reliable improvement
and close to 50 per cent recover.

What treatment strategies work well?

DC: Initially the focus of the IAPT
programme was cognitive
behavioural therapy. CBT is recommended
for depression and all
anxiety disorders by the UK’s National
Institute for Health and Care
Excellence (NICE). For mild to moderate
depression, NICE also
recommends treatments such as
counselling and couples therapy, so
those are offered as well. This is all about
evidence-based
treatment. CBT is backed by the most
evidence, but it’s not the only
show in town.

What makes CBT so effective?

DC: There is emphasis on having an
empathic, supportive therapist.
But it’s called CBT because it focuses on
thoughts (cognitions) and
behaviours. The key idea is that when
people have emotional
problems, negative patterns of thinking -and the way these
influence behaviour – are what keep the
problems going.

How would you use it to treat social
anxiety, say?

DC: People with this condition have
distorted mental images of how
they appear to others. One way CBT might
deal with this is to video
their interactions, then have them compare
the video with their
images of themselves.

Your behaviour also changes if you’re
frightened of talking to
people. If I’m worried you might think what
I say is stupid, chances
are, while we’re talking, I’d be lost in my
head memorising things
I’ve said. So what I’m doing to manage my
anxiety actually gives the
impression that I’m not interested in you. In
therapy you help
people discover that such mental
strategies can make things worse,
and encourage them to drop those
strategies.

How do you know if it’s working?

RL: Each time someone is seen, they
complete a simple measure of
anxiety and depression DC: Prior to this
initiative, you couldn’t go
to any mental health service and ask: “If I
came to you to treat my
anxiety or depression, what is my chance
of recovery?” They didn’t
have complete enough data to answer the
question. In just the last
three months, about 85,000 people
completed a course of treatment
with IAPT, and there is pre and post-treatment outcome data on 98
per cent of them.

This has never happened anywhere in the
world. It is a revolution.
Now those who commission mental
healthcare are realising you can set
goals based on outcomes – not for reduced
waiting times or more
people coming in, but for whether people
actually get better.

How long does it take to make a difference
for one person – and how
much does it cost?

RL: For depression and anxiety disorders,
NICE guidelines suggest
that about half of people will recover within
10 sessions. So far
for IAPT, the average cost is about £650
per person. This is not
expensive treatment. Moreover, it can
prevent public spending on the
disability that mental illness can lead to.
Our case is that these
treatments would actually cost the UK
nothing if they were provided
more widely.

How much does mental illness cost
societies?

RL: For any advanced country, it’s about 8
per cent of GDP. In the
UK, the estimate is nearly £130 billion.
There are now laws here and
in the US that require equal esteem for
mental and physical health,
but we’re still nowhere near truly equal
access to treatment.

In the UK’s National Health Service,
treatments are still not
provided to NICE guidelines. In the US,
health insurers often offer
just six sessions of psychological therapy -then you have to
reapply if you need more. That’s like saying
if a surgical operation
takes over an hour, please reapply to
continue.

It seems you still have a battle ahead. Why
are things moving so
slowly?

RL: The problem is that there’s no
constituency. It’s less a matter
of opposition than not enough people
making the proposition, largely
because of stigma associated with mental
illness. People will fight
for more resources for cancer or heart
disease. But when it comes to
mental illness, there’s no effective lobby.

What could change this?

RL: It requires an uprising by the general
public. If ill people
themselves are not able to protest by virtue
of their illness, we
need to hear much more from their
relatives, friends and colleagues.
Where healthcare is provided in a
democracy, politicians respond to
the number of letters that make the point.

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