NHS news on the 14 May 20181 is certainly arresting. It announced early results from a Cambridgeshire and Peterborough trial of an IAPT service “to integrate mental and physical treatments.” For people with diabetes, cardiovascular or respiratory illnesses there was a three-quarters reduction in inpatient hospital attendance and a two-thirds drop in Accident and Emergency admissions. This is a truly astonishing result, although I could not find a report of the study online citing the evidence to back it up. There is currently a plan to place “3,000 mental health therapists” into GP surgeries “to offer combined mind and body care to patients.” It is claimed that one in three of the more than 16 million people in England diagnosed with a long-term physical health condition experience a mental health problem. It is pointed out that depression and anxiety are also commonly experienced in people with medically unexplained symptoms. The new initiative is seen as a win-win deal: benefit to patients and a saving of tax-payers’ money.2,3 Fifteen new sites for integrated physical/mental IAPT services have been announced.4
The sceptic in me asks what combining or integrating IAPT treatment with physical health care amounts to in practice. Having worked in a general practice centre in the 1970s and spent seven years working closely with hospital physicians in the 1980s, I am totally convinced of the value of this kind of work. The NHS proposal to expand this integrated approach using IAPT therapists is a kind of catch-up exercise. Numerous mental health professionals and counsellors have been working in physical health care settings for decades. There must be at least a couple of dozen academic journals, national or international, reporting on research and practice in this field.
The way the proposed service is being sold is not encouraging. The problem is seen as one of co-morbidity: “Two thirds of people with a long term physical health condition also have a co-morbid mental health problem, mostly anxiety and depression. In addition, up to 70% of people with medically unexplained symptoms also have depression and/or anxiety disorders. These common mental health disorders are detectable and treatable.”
Co-morbidity is a non-starter as a foundation for this kind of work. It provides absolutely no insight into the way physical, psychological, and social factors interact. It is of course true that accurate medical diagnosis is essential. In one area I am familiar with (vestibular dysfunction) the relationship with psychosocial factors is complex, and knowledge of a range of disorders is essential. This means that any therapist “treating anxiety or depression” would need to have a significant grasp of relevant medical conditions and the physical treatments/rehabilitation in common use.
It is stated that the ‘competency framework’ will be based on the one outlined by two academic clinical psychologists, Anthony Roth and Stephen Pilling.5 This framework presupposes the level of competence expected of a clinical psychologist (i.e. someone with a psychology undergraduate degree and a three year applied doctorate). The assumption of these authors seems to be that IAPT therapists would be offering manualised treatments that have been validated in randomised control trials. This is a rather optimistic assumption. As they say: “Many clients present with co-existing conditions, and although this is well-recognised in clinical practice, there is little research examining the most effective packages of treatment for this group. As such, determining the treatment pathways most likely to address their needs will rely on clinical judgment (based on careful engagement, assessment and formulation).” They point out “that a traditional mental health perspective may not be the most useful way of formulating their difficulties” and “foregrounding functioning over symptom change may make sense.” Their competency framework identifies seven domains but “not all of these competences are needed to carry out a psychologically-informed intervention, particularly because these interventions will usually be conducted by individuals without an in-depth training in psychological therapy.” This is really an admission that IAPT therapists will be a cheaper and, quite probably, an insufficiently sophisticated workforce. Their view is that “the framework is intended to accommodate a range of clinicians – from non-specialist healthcare workers who will be implementing psychological interventions as part of their clinical practice to practitioners implementing psychological therapies. It would be unrealistic (and indeed unnecessary) for the former group to acquire competence across all domains of the framework.” By contrast, they seem to be suggesting that at a higher level of competence, it would be necessary “to create a tailored formulation of the individual’s difficulties and to feedback the results of a treatment plan . . . Psychological treatments cannot be delivered in a ‘cook book’ manner.”
The integration of physical health care with a psychosocial perspective is welcome. Only time will tell whether this NHS initiative is the best way to take it forward.
Sources:
1. NHS England News. Mental health “game-changer” care leads to 75 per cent reduction in hospital admissions https://www.england.nhs.uk/2018/05/mental-health-game-changer-care-leads-to-75-reduction-in-hospital-admissions/
2. The Improving Access to Psychological Therapies (IAPT) Pathway for people with long-term physical health conditions and medically unexplained symptoms. https://www.rcpsych.ac.uk/pdf/IAPT-LTC_short_guide.pdf
3. NHS England. Long Term Conditions and Medically Unexplained Symptoms. Available from: https://www.england.nhs.uk/mental-health/adults/iapt/mus/
4. NHS England. Wave two Integrated IAPT sites. Available from: https://www.england.nhs.uk/mental-health/adults/iapt/mus/wave-two-integrated-iapt-sites/
5. Roth, A. D. and Pilling, S. A competence framework for psychological interventions with people with persistent physical health conditions. Available from: https://www.ucl.ac.uk/drupal/site_pals/sites/pals/files/migrated-files/Physical_Background_Doc.pdf