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IAPT at 10: Achievements and challenges

To mark 10 years of Improving Access to Psychological Therapies (IAPT), Professor David M Clark, one of the founders of the programme which has inspired similar models across the globe, reviews the growth and successes of this landmark psychological therapy service during its first decade. Plans set out in the NHS Long Term Plan build on the ambitions of the Five Year Forward View for Mental Health, and will see the number of people with anxiety disorders or depression who can access help each year through IAPT increase by an additional 380,000 to reach 1.9 million by 2024.

The Improving Access to Psychological Therapies (IAPT) programme started in October 2008. The National Institute of Health and Care Excellence (NICE) had recently issued clinical guidelines recommending psychological therapies as first choice interventions for depression and anxiety. Patient preference studies showed these recommendations were popular. Psychological therapies were preferred to medication at a ratio of 3:1. However, the public was not getting what it wanted. Very few people with depression or anxiety disorders were being offered evidence-based psychological therapy and waiting lists were inordinately long.

A revolution in mental health

To overcome this problem, the NHS has trained over 10,500 therapists and deployed them in new psychological therapy services. Each IAPT service follows stepped care principles. NICE recommends cognitive behavioural therapy (CBT) for depression and all anxiety disorders, so it is available in all services. NICE also recommends other therapies for depression and most (93%) services provide patient choice. Counselling is the most commonly offered alternative. In a unique exercise in public transparency, IAPT ensures that almost everyone (99%) who has a course of treatment has their anxiety and depression measured at the beginning and end of treatment. Service outcomes are available on public websites (see NHS Digital IAPT reports and Public Health England’s Profiles Tool). Learning from this data has improved understanding of how to best deliver the therapies and has enabled services to progressively improve the help they provide to patients.

Achievements

IAPT has grown each year since 2008. It now sees over 1 million people each year. Around 550,000 have a course of therapy. The others receive an assessment, advice and signposting (if appropriate). Waiting times are much improved. The latest data show the average wait to be seen is 19 days. Overall outcomes are good. Approximately, 7 of every 10 people (67%) who have a course of treatment (two or more sessions) show reliable and substantial reductions in their anxiety/depression. Around 5 in every 10 (51%) improve so much they are classified as recovered.

The below charts show the number of people seen in IAPT services 2009 to 2018 and IAPT recovery rate, 2009 to 2018.

Number of people seen in IAPT services 2009 to 2018. The graph depicts the number of patients seen in IAPT for at least one attended session each year since 2009. In 2009, 181,947 people attended at least one appointment in IAPT services. This number steadily increases each year thereafter. In 2010 383,138 people attended, 2011 524,831 people, 2012 599,873 people, 2013 703,939 people, 2014 821,352 people, 2015 953,325 people, 2016 965,275 people, 2017 1,009,057 people, and 2018 1,067,223. IAPT recovery rate, 2009 to 2018. The graph indicates the national recovery rate achieved by services since 2009 against the national standard of 50%. The recovery rate recorded each year from 2009 to 2018 is 37.4%, 39.3%, 44.3%, 45.9%, 44.1%, 45.0%, 46.3%, 49.3%, 50.8%, and 51.9% respectively. The recovery rate is derived by counting the number of people that were above the clinical cut-off before treatment but below following treatment. IAPT looks at change in a person, not just in a syndrome. For this reason, an individual is defined as a case if they score above the clinical threshold on depression and/or anxiety at pre-treatment. Recovery occurs if that person subsequently scores below the clinical threshold on measures for both depression and anxiety.

Psychological treatments are more difficult to deliver than medication. Some reduction of clinical outcomes might be expected when treatments are delivered in routine services, rather than in the research studies that underpin NICE guidance. However, IAPT aimed for similar results, specifically at least 50% recovery. Initially, this was an elusive target but was achieved in January 2017 and has been maintained each month since. This remarkable achievement is a testament to the skill, tremendous hard work, openness to learning, and dedication of the thousands of clinicians and other staff who work in IAPT services.

International praise

IAPT has attracted favourable international attention. In 2012 an editorial in science journal Nature stated that the programme “represents a world beating standard”. More recently (December 2018) a piece in the Canadian Globe and Mail was headed ‘For better mental-health care in Canada, look to Britain’. Building on the UK model, Norway now has 40 IAPT services. Australia’s New Access for depression and anxiety programme is strongly influenced by IAPT, Stockholm has a very successful IAPT service, and several other countries are developing plans for IAPT-like services.

Future challenges

Despites its successes, IAPT is still a work in progress. Most people suffering from anxiety or depression in the community still do not have an opportunity to access psychological therapy. For this reason, the NHS Long-Term Plan commits the NHS to expanding IAPT so 1.9 million people are seen each year by 2024. That represents around a quarter of the latest prevalence figures for depression/anxiety.

To achieve this expansion, all IAPT services need to increase their workforce. While this is happening, commissioners and service leads will want to ensure the quality standards that underpin IAPT’s excellent outcomes are maintained. To help, NHS England’s IAPT Manual summarizes 10 years of learning and covers all the essential features of an IAPT service. Areas requiring particular attention include:

  • adequate doses of treatment,
  • reducing waits between initial assessment and subsequent treatment,
  • patient choice,
  • staff well-being initiatives,
  • equal access to IAPT for people with a long-term physical health conditions (LTCs) as well as a mental health problem, and
  • capitalizing on developments in digital healthcare.

New integrated IAPT services which bring together physical and mental healthcare are now established in a third of clinical commissioning groups (CCGs) and have greatly increased access to therapy for people with LTCs. Integrated IAPT needs to expand to the whole of England.

Digitally assisted therapies, where patients receive regular support from a therapist but learn many of the key lessons of psychological therapy from online materials, are starting to be used with success and will become a more prominent feature of IAPT. Digital initiatives may also facilitate initial entry into IAPT services and help services more consistently follow-up patients after treatment to help ensure they stay well.

David Clark

Professor David M Clark holds the Chair of Experimental Psychology at University of Oxford and is the National Clinical and Informatics Advisor for the IAPT programme. Along with Lord Richard Layard and other colleagues, he is one of the original architects of the programme. He is well-known for his research on the understanding and treatment of anxiety disorders, especially panic disorder, social anxiety disorder and post-traumatic stress disorder. Recognition of his work includes Lifetime Achievement Awards from the British Psychological Society and the American Psychological Association.

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10 comments

  1. Miss Carole McNamara says:

    The IAPT leaders are thrilled to reach a 50% recovery stat. I want to know where do the IAPT failures like myself seek help? Since 2011 I have tried IAPT services three times. Each time resulted in a failure.

  2. dave says:

    absolute nonsense.

  3. RCC says:

    To manage expectations about the accessibility of IAPT services, in the North West counselling slots are released to several people at a time. Therefore getting access to a counsellor involves a “race” on smartphones to snap up the available slots. For those without a smartphone, or a fine motor skill disability or arthritis, the process is stacked against them. A shame as it is good to see support for mental health services being promoted.

  4. Richard Mason says:

    Can you tell me which individuals comprise the National IAPT Policy Team? I have been unable to identify them. However, I have been impressed by the transparency and accessibility of the Mental Health and Dementia Clinical Network Team which, you have led me to believe, the National IAPT Policy Team report to [see https://www.england.nhs.uk/south/south-west-clinical-network/our-networks/mental-health-dementia-and-neurological-conditions-network/network-team/ and https://www.england.nhs.uk/blog/a-guide-to-improving-access-to-psychological-therapies-services/%5D. David it would be really helpful, and I would be grateful if you could give me this information or direct me to the web page that publicises it.

  5. MichaelB says:

    Has the National Audit Office report into IAPT outcomes been made public yet?

    • NHS England says:

      Hi Michael,

      Thank you for your enquiry. NHS England has not received any report on IAPT from the NAO and is not expecting one.

      Kind Regards
      NHS England

  6. Barry McInnes says:

    This blog presents a version of reality I neither recognise nor accept.

    It is true that IAPT has lessened the geographical inequalities that existed ten and more years ago. It is also true that waiting times are relatively short in most areas.

    It is misleading to say that “Overall outcomes are good.” They are not. From the 2017 – 18 IAPT annual report it is clear that:

    * 29% of referrals don’t enter treatment and 29% have only one treatment appointment
    * 42% of clients that enter therapy don’t complete
    * Barely one in four clients (27.7%) that enter therapy recover.

    Feel free to look at the 2017-18 client flows through IAPT in my blog http://therapymeetsnumbers.com/is-iapt-too-big-to-fail/

    I used to manage a service in which 84% of clients accepted into therapy completed and of those, 85% achieved clinical and/or reliable change.

    There are some exceptionally high performing IAPT services, but I’m really sorry – overall performance is nothing we can celebrate.

  7. Michael Scott says:

    If NHS England invited the manufacturer of a pharmaceutical to review the growth and successes of its’ drug over the last decade eyebrows would be raised. Yet this is precisely what has happened in asking David Clark to comment on his baby (IAPT) with whom he has an ongoing commitment and financial arrangement. In terms of publication bias his piece is off the scale.
    No Independent Replication
    There has never been independent replication of IAPT’s claim to 50% recovery. My own work, which is wholly independent of IAPT and was published in the Journal of Health Psychology last year (see link below) suggests a 10% recovery rate.
    https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0
    Questionnaires Rather Than An Independently Administered Standardised Diagnostic Interview
    IAPT relies on questionnaires completed by clients with the full knowledge of the treating clinician, introducing a ‘demand’ element into the proceedings.

  8. mark Holian says:

    no comment

  9. E Sweet says:

    So who’s paying? The IAPT strategy regarding medically unexplained symptoms is unbelievably reckless. With a dearth of research into misdiagnosis rates it can’t have been properly risk assessed. However, one key UK study showed unacceptably high MUS misdiagnosis rates in secondary care. Rather than being warned about these abysmal rates with measures put in place to improve accuracy in diagnosis, doctors have instead been taught and encouraged to look for psychological causes of any unexplained symptoms and to divert patients into cheap psychotherapies. This bad practice is driven by a desire to cut costs by limiting physical healthcare referrals and investigations. Also, all MUS patients in IAPT are coded with ‘somatization disorder’ that the vast majority do not have, as is clear from the paper that supposedly underpins the economic case for the MUS roll-out. This discriminatory project endangers millions of UK patients per year while the UK lags behind on patient safety. THINK AGAIN