The scandal of common mental illnesses left untreated
Would we tolerate a situation in which the majority of those suffering from diabetes, heart disease, or arthritis were left to fend for themselves, or asked to make do with inferior therapies?
Imagine you are the campaigns manager of a political party. You are aware of a public health crisis that, at any one time, affects a third of the population, reduces life expectancy as drastically as smoking, is more disabling than angina, asthma, or diabetes, and reduces GDP by around 4% each year. You know this crisis can be substantially – and cheaply – alleviated. Wouldn’t you make the issue a central theme in your election campaign?
Not in the UK, it seems. The crisis in question is one of mental health, yet what our politicians propose to do about it remains unclear. If they’re in need of help, they could always start with a careful reading of a new book by the economist Richard Layard and clinical psychologist David Clark.
At the heart of Thrive: The Power of Evidence-Based Psychological Therapies is a bewildering conundrum. Mental illness is extremely common: one in three people will experience a problem at some point during their lifetime; in any one year, 19% of us will suffer from an anxiety disorder, 13% from a substance problem, and 7% from depression. If personal misery on this scale isn’t sufficient to move politicians to action, an annual cost to the exchequer of approximately £28bn (not counting NHS costs) might be expected to do the trick. Yet most people receive no medical help for their conditions, and of the minority that do get treatment, very few receive the most effective form.
This is a scandal that tells us much about the lack of importance our society places on mental health. Were these individuals suffering from a serious and chronic physical ailment, the story would surely be very different. Would we tolerate a situation in which the majority of those suffering from diabetes, heart disease, or arthritis were left to fend for themselves, or asked to make do with inferior therapies?
The injustice is compounded by the fact that we now have effective treatments for a very wide range of psychological problems. Many of these treatments – verified by dozens of randomised controlled trials – are variants of cognitive behavioural therapy, though other therapies such as counselling are effective for certain problems.
CBT is sometimes criticised as an overly simplistic, once-size-fits-all strategy. Layard and Clark remind us that when done properly CBT is far more nuanced. For each problem, clinicians develop and test a specific theoretical model of symptoms and causes and on this basis generate a targeted treatment strategy. The aim is not to create a blithely complacent Stepford population, but to help people achieve meaningful and positive change in their lives.
CBT isn’t merely effective, it is also relatively cheap – certainly when compared to the spiralling costs of medications such as antidepressants. Opponents imply that this is what makes CBT attractive to policymakers, as if price were an index of effectiveness. They overlook the fact that if it were really so appealing to politicians it would be available to all who need it, just like hypertension medication or insulin. Yet most people are utterly unaware of the existence of these new psychological therapies.
Layard and Clark are not, it should be said, disinterested observers. But they certainly know, from extensive first-hand experience, whereof they speak. Clark is arguably the country’s most eminent clinical psychologist and a pioneer in the treatment of anxiety. Layard, a life peer and a leading economist at the London School of Economics, has led the call for happiness to be considered a key criterion of national success. Together, they developed the idea of the Improving Access to Psychological Therapies (IAPT) scheme, which was launched in 2007 with the aim of training 6,000 new therapists and providing help for the 15% of people who develop common mental health problems each year.
IAPT has helped thousands of people, but it’s too small-scale. The problem lies with funding bodies – healthcare commissioners in the UK or insurers in the US – who see psychological therapy as an easy area to cut. “Many will only pay for six sessions of therapy,” say Layard and Clark, “as if it might be all right to authorise half a heart operation.”
Antidepressant medication, on the other hand, is doled out by doctors on an industrial scale. But of course pharmaceutical companies are immensely wealthy and extremely energetic lobbyists. Advocates for psychological therapies cannot compete, though research shows that this is the kind of treatment that people would prefer to receive.
CBT, as Layard and Clark acknowledge, doesn’t work for everyone. And it doesn’t mean that we don’t need to address the causes of mental illness, such as poverty, stress, and lack of social support. But it’s time we got serious about tackling psychological problems, ramping up research and providing people with the treatments that have been proven to work.
Just 5% of the UK health research budget goes on mental health. IAPT is run on a relatively paltry £340m per year. Can we afford to finance this expansion? That’s a question one could hardly imagine being asked in relation to, say, heart disease. Moreover, Layard and Clark argue that it would cost us nothing in net terms, because of savings in welfare payments (such as sick pay) and physical healthcare costs (mental and physical health problems are often interlinked, meaning that we can expect a 20% reduction in physical healthcare costs as a direct result of psychological therapy).
We need to expand radically the IAPT scheme: increasing the number of therapists; boosting the percentage of people with problems who can receive treatment; reducing waiting lists; covering all geographical areas; offering therapy to children as well as adults; including those with chronic physical health conditions; and providing help for those with less common, but often extremely disabling, mental health conditions such as schizophrenia.
Failing to do so, as Layard and Clark conclude, would be “sheer discrimination against those who are mentally ill, and an abuse of human rights … Future generations will be amazed at how blind we were. They will also be amazed that we were so cruel.”