CG123 Common mental health disorders - National Institute for ...

Common mental health disordersthe right service configuration for the delivery of care to specific groups of people hasgained increasing interest with regard to both policy (for example, see Department ofHealth, 1999) and research (for example, evaluating day hospital treatment [Marshallet al., 2001]). Research using randomised controlled trial (RCT) designs has anumber of difficulties; for example, using comparators such as ‘standard care’ in theUS makes the results difficult to generalise or apply to countries with very differenttypes of ‘standard care’.Stepped careCurrently, much of the UK mental health system is organised around the principles ofstepped care. Stepped care (Scogin et al., 2003) is a framework that is increasinglybeing used in the UK to provide a structure for best-practice clinical pathways to care.It is designed to increase the efficiency of service provision with an overall benefit topatient populations. The basic principle is that patients presenting with a commonmental health disorder will ‘step through’ progressive levels of treatment as necessary,with the expectation that many of these patients will recover during the lessintensive phases. High-intensity treatments are reserved for patients who do not benefitfrom low-intensity treatments, or for those who can be accurately predicted not tobenefit from such treatments. Thus, stepped care has the potential for deriving thegreatest benefit from available therapeutic resources (Bower & Gilbody, 2005) andhas been recommended in a number of NICE guidelines including Depression (NICE,2009a) and Generalised Anxiety Disorder and Panic Disorder (With or WithoutAgoraphobia) in Adults (NICE, 2011a).A potential disadvantage of a stepped-care approach is that patients who do notbenefit from low-intensity treatments may still have to undergo such treatmentsbefore a successful outcome is achieved. To maximise the efficiency of care delivery,patients who can be predicted as unlikely to respond to less intensive treatmentsideally should be referred straight to higher levels; that is, care should be ‘stratified’to an extent (Bower et al., 2006). However, prognostic evidence to support such decisionsis currently lacking.Improving Access to Psychological Therapies programmeIn 2004 the economist Richard Layard made the case for a major expansion in theavailability of psychological treatments, which he suggested could bring a significantreduction in the welfare benefits bill and increased tax contributions of those helpedback to work. In 2006 the government established the Improving Access toPsychological Therapies (IAPT) programme, based heavily on the stepped-careapproach. Clark and colleagues (2009) reported on the initial success of two demonstrationsites in Newham and Doncaster, and the IAPT programme proposes a phasednational roll-out by 2013 (to date, over 50% of Primary Care Trusts have an IAPTservice). Self-referral to IAPT services is also actively encouraged, with emergingevidence to suggest that it increases access for vulnerable groups, such as BMEgroups to psychological interventions (Clark et al., 2009). In addition, an analysis ofthe first full year of operation of the first wave of roll-out sites (October 2008 toSeptember 2009) has recently been published (Glover et al., 2010). Anonymous39