Canadian Psychology / Psychologie canadienne
2013, Vol. 54, No. 1, 12–21
© 2013 Canadian Psychological Association
0708-5591/13/$12.00 DOI: 10.1037/a0031258
Honorary President’s Address / Allocution du Président honoraire
Developing and Disseminating Effective Psychological
Treatments: Science, Practice and Economics
assessments and treatments to aid people with mental health problems. Unfortunately, in most countries only a small proportion of
people with such problems have been able to benefit from such
help. However, there are now real possibilities for expanding the
provision of psychological therapies in many western countries.
Policymakers have long been aware of the individual suffering
produced by mental health problems. Recently, they have also
become aware of the enormous economic cost of untreated mental
health problems. This new awareness, in conjunction with a general political move toward seeing the success of a nation at least
partly in terms of the well-being of its population, has created a
new openness to consider the potential value of psychological
therapies. It is crucial that clinical psychologists respond to this by
promoting the case for the individual, societal, and economic
benefits of making evidence-based psychological treatments more
widely available.
The Canadian Psychological Association is strongly and positively responding to this challenge through the work of its
evidence-based practice task force and other activities. As a fellow
traveller on the road, I am touched to have been selected as the
Association’s Honorary President for 2012. My presidential address covers two aspects of evidence-based therapy. First, how can
psychological science be used to develop new, and hopefully more
effective, psychological therapies? Second, how can these therapies be made more widely available?
DAVID M. CLARK
University of Oxford, United Kingdom
Abstract
In many countries there is growing interest
in the identification, development, and dissemination of evidence based psychological
therapies. The cognitive– behaviour therapy (CBT) movement
has been particularly successful in developing effective new
treatments. It has been suggested this is partly because of the
close interplay between theory, experimental psychopathology,
and treatment development that characterizes much of CBT research. This article provides an illustration of such an interplay
before moving on to discuss one of the world’s largest attempts
to disseminate evidence-based therapies to the general public.
The English Improving Access to Psychological Therapies
(IAPT) program aims to vastly increase the availability of
evidence-based psychological treatments for anxiety disorders
and depression by training an extra 6,000 psychological therapists and deploying them in new, stepped care therapy services.
Outcomes are assessed with a session-by-session monitoring
system that achieves unusually high levels of data completeness.
Around 600,000 patients per year are currently being seen in
IAPT services. The background to the initiative, the scientific
and economic arguments on which it is based, the training and
clinical service models, a summary of progress to date, and future developments are described.
A Strategy for Developing New Therapies
The way in which psychological therapies are developed is
rarely discussed in the literature. Informal discussion with researchers indicates that there are a multitude of routes. My own
research team has pursued a particular strategy over the last 20
years that has proved fruitful in developing effective forms of
therapy for panic disorder (Clark et al., 1994, 1999), hypochondriasis (Clark et al., 1998; Warwick, Clark, Cobb, & Salkovskis,
1996), posttraumatic stress disorder (PTSD; Duffy, Gillespie, &
Clark, 2007; Ehlers, Clark, Hackmann, McManus, & Fennell,
2005; Ehlers et al., 2003; Smith et al., 2007), and social anxiety
disorder (Clark et al., 2006, 2003; Mörtberg, Clark, Sundin, &
Åberg Wistedt, 2007; Stangier, Heidenreich, Pietz, Lauterbach, &
Clark, 2003; Stangier, Schramm, Heidenreich, Berger, & Clark,
2011). Here I briefly describe the strategy in the hope that it may
prove a useful template for other researchers.
Our work has focused on developing new forms of cognitive
therapy. The strategy (Clark, 2004) has been to: (a) use clinical
interviews and cognitive psychology paradigms to identify the
Keywords: dissemination, cognitive-behaviour therapy, anxiety disorders,
social anxiety, depression, outcome monitoring, cost-effectiveness, IAPT
Clinical psychology is at a potentially important moment in its
history. For decades clinical psychologists have been providing
David M. Clark’s research is supported by a grant (069777) from the
Wellcome Trust and by the U.K. National Institute of Health Research
(NIHR). The author is the National Clinical Advisor for IAPT. The
opinions expressed in this article are his own and do not necessarily
represent those of the United Kingdom Department of Health.
Correspondence concerning this article should be addressed to David M.
Clark, Department of Experimental Psychology, University of Oxford,
South Parks Road, Oxford OX1 3UD, United Kingdom. E-mail:
[email protected]
12
HONORARY PRESIDENT’S ADDRESS
core cognitive abnormality in an anxiety disorder; (b) construct a
theoretical account that explains why the cognitive abnormality
does not self-correct; (c) test the hypothesised maintaining factors
in rigorous experimental studies; (d) develop specialized cognitive
treatments which aim to reverse the empirically validated maintaining factors; and (e) test the efficacy of the treatments in
randomized controlled trials.
The Example of Social Anxiety Disorder
I would like to use social anxiety disorder as an example of how
this strategy has been deployed. Social anxiety disorder is one of
the most common anxiety disorders with a lifetime prevalence of
up to 12% (Kessler, Berglund et al., 2005) and a 12-month prevalence of up to 7% (Kessler, Chiu, Demler, & Walters, 2005).
Prospective, longitudinal studies (Bruce et al., 2005) show that it
is also particularly persistent in the absence of treatment. Given
this point, it is concerning that the condition can severely impact
on many areas of life, including educational achievement, interpersonal relationships, and work.
13
ious they look because they erroneously assume that they look as
anxious as they feel. The third process is the use of safety behaviours (often mental operations), which are motivated by the desire
to prevent or minimise feared outcomes (such as “I will appear
boring”) but have the consequence of preventing patients from
discovering that their fears are excessive. In addition, safety behaviours can “contaminate” the social interaction by making it
appear as though the person with social phobia is not interested in,
or dislikes, other people. For example, someone who is worried
that other people might think they are stupid may try to remember
everything they have said in a conversation and compare it with
what they are about to say to ensure that it sounds “clever enough.”
If the conversation goes well they are likely to think afterward that
was only because of the extra monitoring they performed. So, their
basic fear that other people will think they are stupid persists. In
addition, the monitoring may make them appear distracted and
convey the misleading impression that the patient is not interested
in other people. This in turn may elicit less friendly behaviour from
others.
Theoretical Model
Experimental Tests of the Model
In order to develop a theoretical model of the persistence of
social anxiety disorder, Adrian Wells and I interviewed a cohort
of sufferers and synthesized our observations with the results of
existing experimental studies. The resulting model (Clark & Wells,
1995) proposed that the condition is maintained by three interlinked processes. The first is a shift in focus of attention. It is
suggested that socially anxious individuals focus relatively more
attention on observing themselves than observing others when in a
social situation. One of the adverse consequences of such selffocused attention is that they often fail to notice that other people
are responding to them in a reasonably accepting manner. The
second process is the use of internal information (negative selfimagery and feelings of anxiety) to generate excessively negative
impressions about how they think they appear to others. For
example, people with social anxiety often overestimate how anx-
We used a series of experiments and clinical studies to test key
hypotheses in the model. As well as confirming the key hypotheses, some experiments produced unexpected findings that helped
us to further elaborate the model and develop therapy targets.
Mansell, Clark, and Ehlers (2003) investigated whether socially
anxious individuals do indeed shift to a more self-focused mode of
attention under conditions of perceived social threat. High and low
socially anxious individuals performed a task involving simultaneous detection of external and internal stimuli with the relative
speed of detection being used as an index of the direction of
attention. As can be seen from Figure 1, both groups were relatively externally focused in the absence of threat. However, when
they were told that they were about to make a presentation to an
audience, the low socially anxious individuals became more externally focused (perhaps anticipating interacting with the audi-
Figure 1. Focus of attention (assessed by relative speed to detect external and internal stimuli) for high and low
socially anxious individuals when anticipating giving a speech (threat) or not (no threat). Figure derived from
Mansell et al. (2003).
14
CLARK
ence), whereas the high socially anxious individuals became internally focused.
Support for the hypothesis that socially anxious individuals use
internal information to decide how they appear to others was
provided by Mansell and Clark’s (1999) finding of a strong correlation between ratings of subjective anxiety and how one thinks
one appears to others in high socially anxious individuals but not
in low socially anxious individuals. Other studies further explored
the types of internal information that socially anxious individuals
access when making judgments about how they are perceived by
others. A structured interview study (Hackmann, Suraway, &
Clark, 1998) found that patients with social phobia report a high
frequency of negative, distorted self-images in which they see
themselves as if from an observer’s perspective. A subsequent
study (Hackman, Clark, & McManus, 2000) found that these
images were generally recurrent, in the sense that individuals
reported essentially similar content images in a wide range of
different social situations. Furthermore, the images appeared to
date from early, socially traumatic experiences, suggesting that
individuals may construct a negative self-representation in early
life that is not updated in the light of subsequent experience.
Hirsch, Meynen, and Clark (2004) demonstrated that such images
have a causal role by asking individuals with social anxiety disorder to switch between their usual negative self-images and more
realistic images while having a conversation with a stranger. When
holding negative self-images in mind, individuals felt more anxious and thought they came across less well. Their impressions
were distorted in the sense that the other person in the conversation
rated them more positively. However, holding the image in mind
did have an effect on the conversation as the other person rated the
individual as less warm and friendly when he or she was holding
a negative self-image in mind. Other data suggested this was
because individuals used more safety behaviours when they were
dwelling on their negative self-images. Clearly, a small change in
self-imagery can trigger a complex chain of cognitive and behavioural events.
Wells et al. (1995) provided a particularly clear demonstration
that safety behaviours play a key role in maintaining social anxiety
by asking patients to use, or avoid using, their usual safety behaviours during a stressful social interaction. Avoiding using safety
behaviours led to a reduction in anxiety in a subsequent behaviour
test, whereas using the safety behaviours did not.
cused attention are trained. The first is externally focused evaluative attention that is used during behavioural experiments in order
to collect specific information related to the patients’ negative
predictions (e.g., did other people think I was boring?). The second
is externally focused nonevaluative attention in which patients are
taught how to get lost in conversations and social interactions
without thinking about how they might be coming across. The
latter is the long-term aim of therapy; (e) techniques for dealing
with distorted self-imagery, including video feedback and rescripting of early memories associated with the development of a
self-image; and (f) surveys to collect data on other people’s beliefs
about issues such as blushing, trembling, sweating, and so forth.
Unlike in some forms of cognitive– behaviour therapy (CBT),
patients are not encouraged to develop positive self-talk before or
during social situations, and there is no formal social skills training. Instead the emphasis is on testing ones beliefs in action and
reversing the cognitive and behavioural processes that have been
maintaining the beliefs. Several procedures in the treatment (e.g.,
experiential exercises to demonstrate the effect of self-focused
attention) were initially developed in the experimental studies and
then transferred directly into the treatment.
Evaluating the Treatment
Cognitive therapy (CT) derived from the model has now been
evaluated in six randomized controlled trials, conducted in the
United Kingdom, Sweden, and Germany. Figure 2 illustrates the
results of one of the trials (Clark et al., 2006) in which CT was
compared with a well-known behavioural treatment (exposure in
vivo) and no treatment (waitlist control). CT and exposure in vivo
were both effective. However, CT led to significantly greater
improvement at both posttreatment and 1-year follow-up. Eight-six
percent of patients treated with CT no longer met diagnostic
criteria for social anxiety disorder, compared with 45% of those
who received exposure. The other trials found that CT was superior to two forms of Group CBT (Mörtberg et al., 2007; Stangier
et al., 2003), interpersonal psychotherapy (Stangier et al., 2011),
psychodynamic psychotherapy (Leichsenring, 2012), fluoxetine
(Clark et al., 2003), medication-based treatment as usual (Mörtberg et
al., 2007), and pill placebo (Clark et al., 2003). Such broad evidence for differential effectiveness is rare in psychotherapy re-
Developing a New Treatment Based on the Model
We developed a specialized form of cognitive therapy that
specifically focuses on the cognitive abnormalities and maintaining processes specified in Clark and Wells’ (1995) model. The
treatment is delivered on an individual, as opposed to group, basis.
Key procedures include the following: (a) developing an individual version of Clark and Wells’ (1995) model using the patient’s
own thoughts, images, attentional strategies, safety behaviours,
and symptoms; (b) experiential exercises in which self-focused
attention and safety behaviours are systematically manipulated
during social interactions in order to demonstrate their adverse
effects; (c) behavioural experiments in which patients test their
negative predictions while dropping their safety behaviours and
focusing externally during social interactions; (d) systematic training in externally focused attention. Two types of externally fo-
Figure 2. Social Anxiety Composite severity measure at pretreatment/
wait, posttreatment/wait 3 month and 1-year follow-up. CT ⫽ cognitive
therapy; EXP ⫹ AR ⫽ exposure in vivo and applied relaxation; WAIT ⫽
wait list control. Figure derived from Clark et al. (2006).
HONORARY PRESIDENT’S ADDRESS
search and suggests that there is some merit in pursuing a strategy
in which experimental and clinical studies are closely interwoven
in the process of treatment development.
Making Evidence-Based Treatments More Widely
Available
While it is pleasing when the hard work of one’s team eventually results in the development of an effective psychological treatment, such apparent progress will have little impact on mental
health in the community unless the treatment can be made widely
available. This is not easy. When a pharmaceutical company
develops a new drug that has beneficial effects, it invests enormous
sums of money on lobbying the medical profession and on marketing in order to ensure that the drug is widely used. There is no
equivalent process for psychological treatments. Development of
psychological treatments is usually publically funded. Governmental and charity research bodies have multiple calls on their
scarce resources and generally cannot invest in the dissemination
of their research products. As a consequence, developments in
evidence-based psychological treatments often have only a limited
impact on the community.
In order to overcome this problem in England, a coalition of
researchers, clinicians and economists worked together in 2004 –
2005 to bring to the attention of the government the potential
benefits to society, and to the economy of vastly increasing public
access to evidence-based psychological treatments for depression
and the full range of anxiety disorders. Thankfully, the government
listened and committed to a large scale Improving Access to
Psychological Therapies (IAPT) program. The next section describes the program, how it developed, what it has achieved so far,
and how it is likely to progress in the future. Of course, every
country is different and I would not wish to be so presumptuous as
to suggest that IAPT would be right for Canada. However, it may
be that some aspects of the program may be of interest to Canadian
Psychologists as you work with your policymakers and health
commissioners to improve the treatment options available to Canadians with mental health problems.
15
2004, NICE systematically reviewed the evidence for the effectiveness of a variety of interventions for depression and anxiety
disorders. These reviews led to the publication of a series of
clinical guidelines (NICE, 2004a, 2004b, 2005a, 2005b, 2006,
2009a, 2009b, 2011) that strongly support the use of certain
psychological therapies. CBT is recommended for depression and
all the anxiety disorders. Some other therapies (interpersonal psychotherapy, behavioural couples therapy, counselling, brief psychodynamic therapy) are also recommended (with varying indications) for depression, but not for anxiety disorders. In the light of
evidence that some individuals respond well to “low-intensity”
interventions (such as guided self-help and computerized CBT),
NICE also advocates a stepped-care approach to the delivery of
psychological therapies in mild to moderate depression and some
anxiety disorders. In moderate to severe depression and in some
other anxiety disorders (such as PTSD), low-intensity interventions are not recommended and instead it is suggested that patients
should at once be offered “high-intensity” face-to-face psychological therapy.
In the second development, economists and clinical researchers
combined resources to argue that increasing access to psychological therapies would largely pay for itself by reducing other depression and anxiety-related public costs (welfare benefits and
medical costs) and increasing revenues (taxes from return to work,
increased productivity, etc.). The argument was advanced in academic articles (e.g., Layard, Clark, Knapp, & Mayraz, 2007), but
also in the more populist pamphlets, such as the Depression Report
(Layard et al., 2006) and We need to Talk (a report sponsored by
numerous mental health and other charities). The latter were
widely distributed to the public and to policymakers. For example,
the Depression Report was included in every copy of a national
newspaper (the Observer) on Sunday 18th June 2006.
The United Kingdom Government was receptive to NICE’s
recommendations and to the broader arguments advanced in the
Depression Report and elsewhere. A general political commitment
to increase the availability of evidence based psychological treatments was secured in 2005. To test the viability of a national
program, two pilot projects (termed “Demonstration Sites”) were
established.
The English Improving Access to IAPT Program
Doncaster and Newham Demonstration Sites
Overview of the Program
The IAPT program aims to vastly increase access to psychological therapies for depression and anxiety disorders by training
6,000 new therapists by 2014 and deploying them in new services
for these conditions. The training follows national curriculae and
initially particularly focused on CBT, because this was where the
manpower shortage was considered greatest. As the programme
matures, training in other National Institute for Health and Clinical
Excellence (NICE)-recommended treatments for depression is also
being made available. The clinical and other outcomes of patients
who access the services are carefully monitored and reported on a
publically accessible website (www.ic.nhs.uk).
Historical Background
The IAPT program had its roots in several clinical and policy
developments. Two deserve particular mention. First, starting in
In 2006 the National Health Service (NHS) in England comprised 154 primary care trusts (PCTs), each of which had responsibility for the health care of its local population. Doncaster and
Newham PCTs were chosen as the pilot sites. Full details of the
clinical services that were developed in the two demonstrations
sites and the outcomes they obtained in their first year can be
found in Clark et al. (2009) and Richards and Suckling (2009).
Briefly, each site received substantial funds to recruit and deploy an expanded workforce of CBT focused psychological therapists. Doncaster had been pioneering the use of low-intensity
therapies (especially guided self-help) and chose to particularly
expand the workforce that delivered these treatments, although
some additional capacity to deliver high-intensity interventions
(face-to-face CBT) was also developed. Many of the guided selfhelp sessions were delivered over the telephone. Newham initially
placed greater emphasis on high-intensity CBT, although it also
operated a stepped care model when appropriate, using a newly
16
CLARK
recruited workforce of low-intensity therapists (subsequently
called Psychological Well-being Practitioners or PWPs). The lowintensity therapies included computerized CBT (cCBT), guided
self-help, and psycho-education groups.
In order to determine whether the demonstration sites were able
to achieve the outcomes one might expect from the randomized
controlled trials that led to NICE’s recommendations for the use of
psychological treatments in depression and anxiety disorders, both
demonstration sites agreed to adopt a session-by-session outcome
monitoring system that had demonstrated its worth in achieving
high levels of prepost treatment data completeness in community
samples (Gillespie, Duffy, Hackmann, & Clark, 2002). At every
clinical contact, patients were asked to complete simple measures
of depression (Patient Health Questionnaire (PHQ-9); Kroenke,
Spitzer, & Williams, 2001) and anxious affect (GAD-7; Spitzer,
Kroenke, Williams, & Lowe, 2006). If specific anxiety disorders
(agoraphobia, social phobia, obsessive-compulsive disorder
[OCD], PTSD, etc.) were being treated, patients were also encouraged to complete a validated measure of that disorder (e.g., the
Revised Impact of Events Scale in PTSD; Weiss & Marmar,
1997). This is because the GAD-7 does not cover key features of
specific anxiety disorders, such as phobic avoidance, compulsive
behaviour, and intrusive thoughts, images, or impulses.
The main findings from the first year of operation of the two
demonstration sites were as follows:
Clinical problems. The two sites saw somewhat different
populations. In Doncaster referral letters mentioned depression as
the main problem in 95% of cases. In the remaining 5% anxiety
was mentioned as the main problem, mainly generalised anxiety
disorder (GAD; 3.9%). In Newham main problems were as follows: depression (46% of patients), anxiety disorders (43%), and
other problems (11%).
Numbers seen. Taken together, the two sites saw an impressively large number of people (over 3,500) in the first year, with
the use of low intensities therapies and stepped care being the key
ingredients for managing large numbers.
Data completeness. The session-by-session outcome monitoring system ensured that almost all (over 99% on Doncaster and
88% on Newham) patients who received at least two sessions had
pre- and posttreatment outcome scores. For patients who discontinued therapy earlier than expected, the scores from the last
available session were used as posttreatment scores. As well as the
new session-by-session outcome monitoring scheme, the sites also
obtained outcome data on the CORE-OM (Barkham, Margison, &
Leach, 2001) using a more conventional pre- and posttreatment
only data collection protocol. As is usual in community samples,
this protocol produced a much lower data completeness rate (6% in
Doncaster, 54% in Newham), mainly because of missing posttreatment scores. Figure 3 shows the mean improvements in depression
(assessed by the PHQ-9) and anxiety (assessed by the GAD-7) in
patients treated in Newham who did, and did not, provide posttreatment data on the conventional (CORE-OM based) outcome
monitoring protocol. Patients who failed to provide posttreatment
data on the conventional system showed less than half of the
improvement of those who provided posttreatment data. This finding led the IAPT national team to conclude that services that have
substantial missing data rates are likely to overestimate their
effectiveness. For this reason, session-by-session outcome monitoring was adopted in the subsequent national rollout of IAPT (see
below).
Outcomes. The high level of data completeness on the PHQ-9
and GAD-7 made it possible to accurately assess any clinical
improvements that patients achieved while being treated in the
demonstration sites. All patients who received at least two sessions
(including assessment) were included in the analysis, irrespective
of whether they were coded as completers or drop-outs by their
therapist. As a group, patients treated in both sites showed large
improvements (prepost treatment uncontrolled effect sizes of
Figure 3. Improvement in Patient Health Questionaire (PHQ-9) and GAD-7 scores between initial assessment
(pre) and last available session (post) in people who either completed both the pre- and posttreatment CORE-OM
or who failed to complete the CORE-OM at post. Data from the Newham Demonstration site. Figure derived
from Clark et al. (2009).
HONORARY PRESIDENT’S ADDRESS
0.98 –1.26). Individuals were considered clinically recovered if
they scored above the clinical cut-off on the PHQ and/or the GAD
at pretreatment and below the clinical cut-off on both at posttreatment. Using this criterion, 55% (Newham) and 56% (Doncaster) of
patients recovered.
The economic argument for IAPT (Layard et al., 2007) assumed
that such clinical improvements would be largely sustained and
that there would be improvement in employment status as well as
symptoms. To see whether the clinical improvements were sustained, patients in both sites were asked to complete the outcome
measures 9 months (on average) after discharge. Among those who
provided data gains were largely maintained. It had been assumed
that IAPT services would achieve an overall improvement in
employment status in 4% of the total treated cohort (Layard et al.,
2007). The observed rate was 5%.
Although the outcomes observed in the demonstration sites were
broadly in line with expectation, it is important to realise that the
sites were not set up as randomized controlled trials, and it is likely
that some of the observed improvement would have happened
anyway (e.g., natural recovery). Various studies suggest that natural recovery rates over a period of time that is similar to the
duration of IAPT treatment are high among recent onset (⬍6
months) cases of depression and anxiety disorders but are substantially lower among more chronic cases. Building on this observation, Clark et al. (2009) separately computed the recovery rates
among recent onset and chronic cases. Most cases had been depressed or anxious for over 6 months and it seemed safe to
conclude that treatment had provided added benefit to this group as
the recovery rates (52% at each site) comfortably exceeded the
5%–20% one might expect from natural recovery or minimal
intervention. However, among the minority of cases with a recent
onset, it was not possible to exclude the possibility that much of
the improvement may have been because of natural recovery (see
Clark et al., 2009, p. 919).
The National Rollout of IAPT
Following the success of the Newham and Doncaster Demonstration sites, the Government announced a phased national rollout
that would last several years (Department of Health, 2008, 2010).
Funding for the first 3 years (approximately Canadian $470 million) was announced in 2007, with funding for a further 4 years (up
to Canadian $630 million) announced in February 2011. The initial
funding was allocated to train up to 3,600 new psychological
therapists (60% high-intensity CBT therapists, 40% PWPs) and to
deploy them, along with existing experienced clinicians, in new
psychological treatment services that would operate on stepped
care principles. The training programme initially focused on CBT
because (a) it is recommended by NICE for both depression and
anxiety disorders and (b) it is the therapy where the manpower
shortage was considered to be greatest. The further funding is to
train an additional cohort of 2,400 PWPs and high-intensity CBT
therapists and to also train therapists in four other therapies that
NICE (2009a) recommends for some depressed individuals but not
for anxiety. The four therapies are interpersonal psychotherapy,
behavioural couples therapy, counselling for depression, and brief
psychodynamic therapy.
Targets were set for the number of patients that would be seen
by the services and there was an expectation that as the services
17
matured 50% would “move to recovery” in terms of their symptomatology. In addition, it was expected that fewer people would
be on sick pay or receiving state benefits. At least 20 of England’s
154 PCTs were expected to establish new “IAPT” services during
the first year, with further PCTs joining in future years. A large
number of documents providing guidance to courses and PCTs
were produced, most of which can be viewed on the IAPT website
(http://www.iapt.nhs.uk). Table 1 lists the key documents.
Training. To facilitate training of the new workforce, the
Department of Health commissioned and distributed separate national curriculae for the training of high-intensity CBT therapists
and PWPs. Because the main aim of the IAPT programme is to
increase the availability of treatments recommended by NICE, the
high-intensity CBT curriculum is closely aligned to the particular
CBT programmes that had been shown to be effective in the RCTs
that contributed to NICE’s recommendations. A wide range of
general CBT assessment and intervention strategies are included in
the curriculum. In addition, trainees are required to be taught at
least two evidence based treatments for depression (cognitive
therapy and behavioural activation) and at least one specific,
evidence-based treatment for each anxiety disorder. In panic disorder examples include Barlow and colleagues’ CBT programme
and Clark & colleagues’ cognitive therapy programme. In social
anxiety disorder, examples include CT based on Clark and Wells’
model and Heimberg’s CBT program. Roth and Pilling (2008)
developed a competency framework for many of the leading,
empirically supported CBT treatments for depression and anxiety
disorders and the high-intensity curriculum aims to ensure that
these are covered in IAPT training programmes. In addition to
specifying the skills that trainees should acquire, the curriculum
also specifies how these skills should be assessed (through a
mixture of ratings of actual therapy sessions and written assignments in the form of case reports and essays).
A separate curriculum was issued for PWP training. The four
sections of the curriculum cover (a) engagement and assessment;
(b) evidence-based low-intensity treatments; (c) values, policy,
culture, and diversity; and (d) working within an employment,
social, and health care context. Both the high-intensity CBT and
Table 1
Key Improving Access to Psychological Therapies (IAPT)
Reference Documents With Publication Dates in Parentheses,
When Relevant
IAPT Implementation Plan: National guidelines for regional delivery
(February 2008)
IAPT Implementation Plan: Curriculum for high-intensity workers
IAPT Implementation Plan: Curriculum for low-intensity workers
IAPT Impact Assessment (February 2008)
IAPT Equality Impact Assessment (February 2008)
IAPT Supervision Guidance
IAPT Commissioning Toolkit (April 2008)
Realising the Benefits: IAPT at Full Roll-Out (February 2010)
The Operating Framework for the NHS in England 2011/12
No Health without Mental Health (February 2011)
Talking Therapies: a Four Year Plan (February 2011)
Which Talking Therapy for Depression
Commissioning Talking Therapies for 2011/12 (March 2011)
IAPT Data Handbook 2
Note. Psychological Therapies (IAPT) Reference Documents (Available
at http://www.iapt.nhs.uk).
18
CLARK
the PWP training programs are conceived as joint university and
in-service trainings. Trainees attend a university base for lectures,
workshops, and case supervision for some of each week. For the
rest of the week they work in an IAPT service. The services are
also encouraged to provide trainees with the opportunity of directly observing therapy sessions conducted by experienced staff.
Recently, training programs for the four non-CBT therapies
supported by the IAPT program have also been launched. As with
the CBT training, these programs follow national curriculae and
are aligned to a published competency framework for each therapy
(details available at www.iapt.nhs.uk).
IAPT service model. A general service framework was outlined in the National Implementation Plan (2008). The framework
specifies key principles for the operation of the services while
leaving considerable scope for local determination. The key principles include:
• A person-centred assessment that identifies the key problems
that require treatment and their social and personal context. Goals
for therapy are identified and a treatment plan is jointly agreed.
• Stepped care in which many people with mild to moderate
depression or anxiety disorders are offered treatment with a PWP
initially. Many people recover with such treatment. Individuals
who do not should be offered a further course of high-intensity
treatment. For people with more severe depression or anxiety and
for everyone with PTSD, immediate high-intensity treatment is
recommended. All treatments that are offered should be in line
with NICE recommendations.
• Access to an employment advisor if employment (lack of, or
danger of losing) is an issue. Services are encouraged to involve
employment advisors in treatment plans from the very beginning
as making progress with employment issues can greatly facilitate
psychological recovery and vice versa.
• Use of the IAPT minimum dataset (see IAPT Data Handbook
2 for full details). This includes giving the PHQ-9 and GAD-7
every session along with some other patient self-report measures
that focus on specific anxiety disorders, when these are relevant.
All data is entered into an electronic database that enables therapists and their supervisors to monitor patients’ progress and adjust
treatment plans, if required.
• All therapists should receive weekly, outcome-informed supervision that ensures that all cases are discussed at regular intervals and decision about step-up/step-down are made in a timely
fashion (see IAPT Supervision Guidance).
• Because of the importance of obtaining outcome data on
almost all patients who receive treatment, the services are asked to
ensure that at least 90% of patients who are seen at least twice in
a service have a pretreatment and posttreatment (or last available
session) score on the main outcome measures.
What Has Been Achieved So Far?
At the time of writing (Summer 2012), we are just over half way
through the rollout of the IAPT programme. Progress to date
includes the following:
• IAPT services have been established in 99% of PCTs. It is
intended that by 2014 the services will be able to see around
900,000 people per year, which equates to 15% of the prevalence
of depression and anxiety disorder in the community. At the
moment they are seeing approximately 600,000 per year (10% of
prevalence). However, there is wide variation in the number of
therapists employed in the services and, as a consequence, they
vary substantially in the percent of local prevalence that they can
address.
• The initial target of training approximately 3,600 new highintensity therapists and PWPs in the first 3 years has been
achieved. The further cohorts of therapists that are expected to be
trained in the coming years are needed to help all areas reach their
goals in terms of therapy access numbers.
• The percentage of treated patients who meet clinical recovery
criteria has steadily increased as the programme progresses and is
now running at an average of 46% (data from last quarter year). Of
course, it is possible to achieve worthwhile gains without making
a full recovery. Consistent with this, an analysis of the year one
data (Gyani, Shafran, Layard, & Clark, 2011) found that 64% of
patients showed statistically reliable improvement. Calculations of
recovery and reliable improvement rates are based on individuals
who had at least two sessions and have finished their involvement
with the services (even if they dropped out). A sizable proportion
of people are only seen once (often being assessed, offered advice,
and perhaps signposted to services such as debt counselling and
housing assistance). A systematic system for assessing their outcomes has yet to be developed. Finally, numbers moving of sick
pay and state benefits are in line with the program targets.
Lessons From the First Phase of the Program
As well as the broad performance figures given above, the
United Kingdom Department of Health has released two reports
that provide more detailed analysis of the IAPT program during its
first year of operation (1st October 2008 to 30th September 2009).
During this period 35 health areas (PCTs) established an IAPT
service, 32 of whom provided data for analysis.
The first report (Glover, Webb, & Evison, 2010) focused on
issues to do with equity of access, descriptions of the treatments
offered, and overall outcome. With respect to equity of access,
both genders were fairly represented in the year one IAPT services.
The most recent Adult Psychiatric Morbidity Survey (McManus,
Meltzer, Brugha, Bebbington, & Jenkins, 2009) shows that 61% of
people in the community with a common mental disorder are
female, which was very similar to the rate in IAPT services (66%
female). However, people over 65 years old and people from the
black and minority ethnic (BME) groups were somewhat underrepresented. Looking at clinical conditions, it was difficult to
assess equity of access accurately as for 39% of patients a formal
diagnosis was not recorded. However, among the 61% for whom
diagnoses were recorded, there was an overrepresentation of patients with Depression or Mixed Anxiety and Depressive Disorder
(MADD), compared with prevalence rates found in community
studies. There was also under representation of patients with
persistent anxiety disorders, such as PTSD, OCD, panic disorder,
social phobia and agoraphobia, because less than 10% of patients
had these diagnoses, whereas around a third of patients should
have these disorders if access was equitable (see McManus et al.,
2009).
The first report also found that the majority of patients
received NICE compliant treatment. The NICE recommended
low-intensity interventions that were provided included: guided
self-help, psychoeducation groups, behavioural activation,
HONORARY PRESIDENT’S ADDRESS
computerized CBT, and structured exercise. NICE recommends
CBT as a high-intensity psychological therapy for depression
and for all the anxiety disorders that are currently covered by
guidelines. In line with this recommendation, almost everyone
with a recorded diagnosis of social phobia, specific phobia,
agoraphobia, or OCD received CBT. For patients with a recorded diagnosis of GAD or PTSD CBT was also the most
commonly provided treatment. However, a significant number
of patients received counselling, which is not recommended by
NICE for these conditions. For patients with a recorded diagnosis of depression, CBT and counselling were equally likely to
be offered and both are recommended by NICE. Turning to
clinical outcomes, a recovery rate of 42% was observed. However, there was considerable between site variability in recovery
rates.
The second report (Gyani et al., 2011) explored the observed
variability in recovery rates in further detail in order to identify site
and other characteristics that were associated with higher recovery
rates. The analyses focused on patients who were clinical cases on
entry into the service, had received a least two sessions and had
completed their involvement with the services. Pre- to posttreatment data completeness for these patients was good (⬎90%). The
findings, which are briefly summaris(ed) below, generally support
the IAPT clinical model and highlight the value of following NICE
guidelines.
Patients had a higher chance of meeting recovery criteria if they
were treated at sites that had the following characteristics:
• Higher step-up rates from low-intensity to high-intensity therapy among those who had failed to respond adequately to the
former (i.e., the services were making good use of stepped care).
• Higher average numbers of therapy sessions at low-intensity
and at high-intensity (highlighting the importance of providing an
adequate dose of treatment).
Although most patients received NICE-recommended treatments, for some clinical conditions a significant minority of
patients received a treatment not recommended by NICE. This
created a natural experiment in which it was possible to assess
whether deviation from NICE recommendations was associated
with a reduction in recovery rates. One of the natural experiments concerned the contrast between CBT and counselling.
For depression, NICE recommends both treatments for mild to
moderate cases. Consistent with this recommendation, there
was no difference in the recovery rates associated with CBT and
counselling among patients with a diagnosis of depression. In
contrast to the recommendations for depression, NICE does not
recommend counselling for the treatment of GAD. Consistent
with this position, CBT was associated with a higher recovery
rate than counselling among patients with a diagnosis of GAD.
A further natural experiment concerned the contrast between
guided self-help and pure (nonguided) self-help. NICE only
recommends guided self-help in depression. Consistent with
this position, guided self-help was associated with a higher
recovery rate than pure self-help among patients with a diagnosis of depression. Taken together these findings would appear
to support the value of aligning clinical interventions with
NICE guidance. However, this conclusion needs to be treated
with caution because these “natural experiments” are not randomized clinical trials.
19
Future Development of the Program
Full details of the next phase can be found in the mental health
policy entitled No Health Without Mental Health (Department of
Health, 2011a) and in the accompanying document entitled Talking Therapies: Four Year Plan of Action (Department of Health,
2011b).
Briefly, the aim is to complete rollout of the adult depression
and anxiety disorders program and to start a version of IAPT that
focuses on child and adolescent treatment services. There will also
be pilot studies with people with long-term physical health problems in conjunction with depression or anxiety, as well as with
people with psychosis and personality disorders. All will aim for
high levels of prepost treatment data completeness so policymakers and commissioners can assess the clinical benefits and limitations of the work.
Conclusion
It has been a great privilege to hold the post of Honorary CPA
President for 2012. Canada has made enormous contributions to
world psychology over many decades. With guidance from Dr.
David Dozios (your “real” President) and the Evidence-based
Practice Task Force1 that he cochaired with Dr. Sam Mikail, it is
showing leadership in the development of evidence-based practice.
I greatly enjoyed learning about these developments at the national
conference in Halifax, Nova Scotia, this year. In return, I hope that
some aspects of the recent developments in England outlined in
this article may also be of interest to Association members as you
push forward in further developing your mental health services in
a way that is right for Canadians.
Résumé
Dans de nombreux pays, on s’intéresse de plus en plus au
repérage, à l’élaboration et à la diffusion de thérapies
psychologiques fondées sur des preuves. Le mouvement de la
thérapie cognitivo-comportementale (TCC), en particulier, est
parvenue à concevoir de nouveaux traitements efficaces. Selon
certains, ce succès est partiellement attribuable à l’interaction
étroite entre la théorie, la psychopathologie expérimentale et
l’élaboration de traitements qui caractérise une bonne partie de
la recherche en TCC. Le présent article illustre une telle
interaction avant de traiter d’une des tentatives les plus vastes
de diffusion au grand public de thérapies fondées sur des
preuves. Le programme anglais « Improving Access to
Psychological Therapies » (IAPT) (Amélioration de l’accès aux
psychothérapies) vise à accroître considérablement la
disponibilité des traitements psychologiques fondés sur des
preuves pour les troubles anxieux et la dépression. Il compte le
faire en formant 6 000 psychothérapeutes supplémentaires et en
les affectant à de nouveaux services de soins par paliers. Les
résultats sont évalués par un système de suivi d’une séance à
l’autre qui permet d’obtenir des taux exceptionnellement élevés
d’exhaustivité des données. Chaque année, près de 600 000
1
The evidence-based taskforce comprises: Lynn Alden, Peter Bieling,
Guy Bourgon, David A. Clark, David Dozois (Co-Chair), Martin Drapeau,
Dave Gallson, Les Greenberg, John Hunsley, Charlotte Johnston, and Sam
Mikail (Co-Chair).
CLARK
20
patients font appel aux services de l’IAPT. L’article présente le
contexte de l’initiative, les arguments scientifiques et
économiques sur lesquels celle-ci repose, les modèles de
formation et de service clinique, un résumé des progrès
accomplis jusqu’à présent et les prochaines étapes.
Mots-clés : diffusion, thérapie cognitivo-comportementale, troubles anxieux, dépression, suivi des résultats, rapport coûtefficacité, IAPT.
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Received October 6, 2012
Revision received November 9, 2012
Accepted November 13, 2012 䡲