The case for psychological treatment centres
BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7548.1030 (Published 27 April 2006) Cite this as: BMJ 2006;332:1030
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The Editor
Layard makes a strong economic case for investment in the treatment
of depression and anxiety in primary care settings. However, there are
many potential pitfalls in the outsourcing (for that is what it would be)
of psychological treatment.
Depression, as pointed out elsewhere in this issue, has many
characteristics of a chronic disorder. Kessler et al (1) showed that 72%
of patients had more than one episode. Judd et al (2) showed that
patients moved between levels of severity, and were ill for 59% of weeks.
These more disabled patients contribute disproportionately to overall
morbidity. They also tend to have needs other than psychological
treatment, eg social problems, the need for occupational rehabilitation,
and physical co-morbidities.
There is a substantial body of evidence which shows that these
patients are best managed using collaborative care and stepped care
models(3). A key factor is integration of care for depression
(psychological and pharmacological) with other aspects of care, both
physical and social. Therefore effective management of these patients
requires the co-ordination of multiple inputs.
Two models are of relevance. The outsourcing of business processes
is now commonplace, but works best with relatively uncomplicated tasks.
Returning to the field of health care, the chronic illness care model(4)
shows that such conditions are best managed in multidisciplinary teams
where there is clarity of role, high quality information and communication
and effective team leadership and management.
The outsourcing of one aspect of care is likely to lead to
preferential referral of less complex cases, and consequent dilution of
the potential health impact investment. .
New investment should instead go to create and strengthen
multidisciplinary primary care mental health teams, which are integrated
with general practice and with specialist mental health services. The
challenge here is to establish the effective team structures required.
This needs not just more trained cognitive therapists, but also effective
clinical leaders and managers.
Suresh Joseph
Consultant Psychiatrist,
Newcastle General Hospital
Newcastle upon Tyne
NE4 6BE
References:
1 Kessler RC, Zhao S, Blazer DG, Swartz M. Prevalence, correlates
and course of minor depression in the national comorbidity survey.
Journal of Affective Disorders 45 (1997) 19 - 30.
2 Judd LL, Hagop SA, Maser JD, Zeller PJ, Endicott J, Coryell W et
al. A prospective 12 year study of subsyndromal and syndromal depressive
symptoms in unipolar major depressive disorders. Arch. Gen. Psychiatry;
55: 694 - 700.
3 Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and
organizational interventions to improve the management of depression in
primary care: a systematic review. JAMA 2003: 289 : 3145-51.
4 Wagner E, Austin B, Von Korff M. Organizing care for patients with
chronic illness. Millbank Q 1996: 74: 511 - 44.
Competing interests:
None declared
Competing interests: No competing interests
Editor- Lord Layard proposes establishing 250 psychological treatment
centres for CBT in the UK. His cost/benefit analysis is based on one new
therapist treating 80 patients a year. One patient would receive 16
sessions
of CBT. This would add up to one therapist delivering 80x16 sessions/year
(each session 50 min therapy plus 10 min documentation), or 1280 hours/
year. Assuming this therapist works effectively 40 weeks/year at 38 hours/
week (1520 therapist hours) he or she in an average week would spend 32
hours seeing patients and documenting sessions, but only 6 hours in
supervision, team meetings, training, corporate induction, focus groups,
appraisals, primary care liaison meetings, drinking tea, chatting with
colleagues. This would be laudable but appears unrealistic. I would
suggest
that in most NHS settings clinicians spend considerably less than 50% of
their
time with clinical work.
Morover, the cost/benefit calculation is presumably based on patients
who
complete therapy. Real world settings (unlike research trials) are
unlikely to
achieve CBT drop-out rates of less than 40%, which would point to max 50
patients/therapist/year completing CBT under the above (over)optimistic
conditions.
Finally, Lord Layard's conclusion: "to achieve a sufficient volume
and quality
of therapy will require in the initial phases a strong lead from the
Department
of Health" certainly lacks in evidence considering the DoH's track record
of
implementing cost-effective mental health services.
The author argues for a more organic, more diverse and less
centralistic
growth in CBT services within the NHS.
Yours sincerely
Dr Martin Zinkler
Competing interests:
None declared
Competing interests: No competing interests
Layard’s vision has already started…
In Layard’s vision, psychological treatment centres will improve
access to individual cognitive behaviour therapy (CBT). Access to CBT has
been improved in Oxfordshire through a Group Programme run by the charity
Mind which focuses on Building Self Esteem, Coping with Anxiety and
Managing Depression.
Group CBT is less widely practised in primary care and thus the
evidence base is not yet established. However, we can learn from
colleagues in the voluntary sector. This may enable the NHS to develop
capacity further and run CBT groups.
I work in partnership with Mind and the Complex Needs Service
(Personality Disorder), observing, supervising and training the Mind group
workers. We evaluate each group and the last sample (n=53), though modest,
showed statistically significant reduction in scores on the Beck
Depression Inventory and Beck Anxiety Inventory and similar improvements
on a self esteem score. Satisfaction measures were high, indicating that
people like to be seen in non-clinical settings (family centres, resource
centres, Mind day services). Learning CBT skills with peers was seen as
particularly powerful in reducing feelings of isolation.
The model involves training non-statutory workers and providing high
quality support and supervision by a clinical psychologist. Our Group
Programme has proved effective, popular and economical. I hope that Group
CBT finds a place in Layard’s vision of a psychologically healthier
future.
Competing interests:
DB provides training and supervision for the Mind Group Programme.
Competing interests: No competing interests
I support the case for psychological treatment centres for
depression as described by Lord Layard. However, the ‘other psychological
therapies’ should not be neglected in favour of CBT. All psychotherapies
are effective in about 70% of their client group. Solution-focused brief
therapy has an evidence base in depression and other conditions as well as
being widely applied to situations in education and management
(www.psychsft.freeserve.co.uk; www.solution-news.co.uk;
www.brieftherapy.org.uk). There are already many NHS staff trained in
this model. It takes four years to train in CBT but four days for a
health professional to learn the basic application of solution-focused
methods. This makes the prospects of improving care of depression much
more feasible within existing resources.
Competing interests:
I am a solution-focused therapist, trainer and management consultant.
Competing interests: No competing interests
The article by Lord Layard purports to identify “The case for
psychological treatment centres”1 yet fails to provide evidence to support
this. On reading his piece, the following issues arise:-
• It cannot be assumed that treatment centres are most effective just
because this is how the clinical trials were conducted. Therefore the
article leaves Lord Layard’s claim that “the expanded provision should be
provided through psychological treatment centres”1 unsubstantiated.
• It is incorrect to state that General Practitioners (GPs) are
“unlikely to prescribe any treatment other than drugs”.
• In trials psychological treatments “typically involve no more than
16 sessions” for patients who meet the selection criteria. In the reality
of day to day practise patients rarely meet these criteria, and are likely
to require more sessions.
• Who will replace the therapists proposed to work in the treatment
centres? Will experienced professionals be taken away from secondary care?
• What immediate provision will there be for new cases of depression
identified by GPs screening all patients with diabetes and heart disease?
“Ninety percent of cases of depression are treated in primary care”2.
Jan Scott’s recognition that “depression is a life course disorder”2 is
crucial. As GPs we care for patients through their life course, and are
well placed to provide ongoing psychological treatments. I am one of a
number of GPs trained in Cognitive Behavioural Therapy, and I am keen to
develop Primary Care led services for depression.
Lord Layard should not ignore what Primary Care can offer in the
treatment of this chronic disease. His arguments rely on supposition. He
employs “assume” and “assuming” far too much, when “joined up thinking”2
is required to organise and provide treatment most effectively.
References:-
1. Layard R, The case for psychological treatment centres. BMJ 2006;
332: 1030-1032.
2. Scott J, Depression should be managed like a chronic disease. BMJ 2006;
332: 985-986.
Competing interests:
I received funding from Wyeth in 2005 to pay for a CBT course.
Competing interests: No competing interests
To the editor:
Professor Lord Layard (BMJ, 2006; 332:1030-2) presents a strong
argument for the need for more practitioners trained in empirically
supported psychological therapies for mood and anxiety disorders, such as
cognitive-behavioural treatments. These therapies are as efficacious as
the leading pharmacotherapies for mood and anxiety disorders, but have the
advantage of having a lower relapse rate than drug treatments. A further
advantage, which was not identified in his article, is that cognitive-
behavioral treatments can be effectively administered in group therapy
format, with groups typically consisting of 6 or 8 patients. Such
treatments are more cost-effective than pharmacotherapies [e.g., 1].
Although such psychological therapies have been available for decades,
there is a woeful shortage of qualified practitioners to deliver these
treatments, both in England and elsewhere in the world, including North
America. Professor Layard estimates that in order to meet the need for
providing empirically supported psychological treatments in England, some
10,000 new therapists must be trained. In order to meet similar needs
elsewhere in the world, the training of tens of thousands of additional
therapists is required. This poses a major problem. Skilled providers in
psychological therapies are typically clinical psychologists or
psychiatrists. University training programs for these specialities are
typically small. A clinical psychology program or psychiatry residency
program might graduate, in any given year, as few as 6 to 12 newly trained
specialists. These training programs are unlikely to have the necessary
resources or number of faculty required to be able to meet the training
needs for thousands of new therapists recommended by Professor Layard.
Where will the additional therapists come from? Professor Layard suggests
that they will come from the allied health professions (e.g., occupational
therapists) who receive “on the job” training. It is unclear whether this
plan would be feasible to produce a sufficient number of suitably
qualified practitioners.
Diploma programs in community colleges or in other institutions could
train large numbers of therapists in a short period of time. But the
question arises as to whether diploma mills can produce therapists with
the sufficient skills for clinical practice. In addressing the important
problem of making psychological therapies available on a large scale, we
face the important challenge of balancing quality with quantity. Poorly
trained therapist, just like poorly trained practitioners in other areas
of clinical practice, may do more harm than good.
Reference
1. Gould, R. A., Otto, M. W., & Pollack, M. H. A meta-analysis of
treatment outcome for panic disorder. Clin. Psychol. Rev; 1995;1 5: 819-
844.
Competing interests:
None declared
Competing interests: No competing interests
EDITOR--It was very interesting to read the paper of Layard 'The case of
psychological treatment centres' [BMJ 2006,332;1030-1032]. I support the
idea of establishing psychological treatment or CBT centres in UK. I think that
with the great development in recent years in mental health services in
UK, with new generation of psychotropic drugs, specialised teams like Home
treatment/Crisis team, Assertive outreach, & Early intervention teams, so
establishing psychological treatment centres will be great move in the
right direction as such centres can work nicely with psychiatric
hospitals, community and specialised psychiatric teams, and general
practice.
AK.Al-Sheikhli, MRCPsych,DPM
Competing interests:
None declared
Competing interests: No competing interests
Is the case for psychological treatment centres supported by the right evidence?
In the article ‘The case for psychological treatment centres' [1],
professor Layard states that a course of psychological treatment will be
likely to result in '12 extra months free of illness' and illustrates his
proposal with an impressive chart reproduced from an article by Fava et al
[2]. In this Italian trial, one experienced therapist (the first author of
the study) treated all 20 patients, using a CBT (cognitive-behavioural
therapy)approach enriched by a 'well being therapy' to treat residual
symptoms after their depression had already responded to a course of
medication. We wonder whether results of this small study can be
extrapolated to the proposed system of 250 psychological treatment centres
with 10 000 therapists and unselected patients. Surely, pragmatic trials
with large and relatively unselected primary care samples of patients with
depression and anxiety are more relevant for predicting the effect of
therapy in such settings [3]. Unfortunately, such 'real world' studies
give more modest estimates of the effectiveness of brief psychological
treatments. In one such pragmatic trial, a course of CBT in 215 patients
with depression lead to a reduction of depressive symptoms at 4 months
compared to care as usual; however, this positive effect did not
generalise to broader outcome measures, such as quality of life, and was
no longer apparent after 12 months [4]. Also the effect of CBT was no
better than that of nondirective counselling and cost analysis did not
show any significant advantage at 4 or 12 months [5]. While we agree that
increased availability of evidence-based psychological treatments is
desirable, the expectations should be based on appropriate 'real world'
evidence, which sets realistic standards.
References
1. Layard R. The case for psychological treatment centres. BMJ 2006;
332: 1030-1032.
2. Fava GA, Ruini C, Rafanelli C, Finos L, Conti S, Grandi S. Six-
year outcome of cognitive behavior therapy for prevention of recurrent
depression. Am J Psychiatry 2004;161: 1872-6.
3. Hotopf M. The pragmatic randomised controlled trial. Advances in
Psychiatric Treatment 2002; 8:326–33.
4. Ward E, King M, Lloyd M, Bower P, Sibbald B, Farrelly S, et al.
Randomised controlled trial of non-directive counselling, cognitive-
behaviour therapy and usual general practitioner care for patients with
depression. I: Clinical effectiveness. BMJ 2000; 321: 1383-1388.
5. Bower P, Byford S, Sibbald B, Ward E, King M, Lloyd M, et al.
Randomised controlled trial of non-directive counselling, cognitive-
behaviour therapy, and usual general practitioner care for patients with
depression. II: Cost effectiveness. BMJ 2000; 321: 1389-1392.
Competing interests:
None declared
Competing interests: No competing interests