Column 316: The Countess of Mar
Health: Cognitive Therapy
Question for Short Debate
Tabled By Baroness Tonge
To ask Her Majesty’s Government what steps they are taking to implement cognitive psychotherapy in the National Health Service.
Baroness Tonge: My Lords, last weekend I was in Syria talking to Hamas leaders. It was very interesting. In the discussions, one of them said, “We love life and happiness as much as any of you do”. I thought that that was fairly profound stuff coming from a group that uses suicide bombers, but I shall save that for another debate. We all love life and happiness and that is what we all want. Sometimes people or events conspire to make us unhappy or sometimes, without any reason, people become depressed. Sir Winston Churchill had his black dog, which was not a bipolar disorder but just good old depression.
I am fortunate never to have suffered. I have been very sad, yes, frustrated, yes, suffered pre-menstrual tension, yes—you should have seen me in those days—but fortunately I have never been depressed. However, I have many patients, friends and relatives who have
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suffered and I have watched their distress. That distress is often increased when they are prescribed antidepressants, which sometimes unjustly have a reputation with the general public of not doing any good.
Depression and its stablemate anxiety are the most common mental health disorders. One in five people will suffer from them at some stage in their lives, with one in 50 suffering from severe depression. People are often reluctant to go to their GPs because, understandably, no one wants mental illness on their medical record—people are afraid that it will affect job prospects in the future.
As the economic situation worsens, more people are forced to face unemployment, debt and loss of self-respect, which can only make depression more likely. This problem is urgent. The treatments currently available are the talking therapies and drugs. Despite the National Institute for Health and Clinical Excellence asking doctors to use drugs with caution, they cost the NHS £400 million per annum.
I have always been enthusiastic about cognitive behavioural therapy, which from now on I shall call CBT. Long ago, I worked in a centre where it was being used. It seeks to teach people skills to tackle their problems. It needs well trained and experienced therapists, which the NHS does not have in great number. Everyone who needs a therapist should be able to access one, but I understand that in some parts of the country it takes up to 18 months for a suffering person to see a psychotherapist. That is useless and unacceptable. Last May, the King’s Fund found that one-third of people suffering from depression were not getting any treatment. That is a lot of human misery. Even so, the cost of treating depression—also according to the Kings Fund—is £1.7 billion per annum. The cost of lost employment is £7.5 billion per annum. The problem is urgent and escalating.
The Government have taken some important steps in recent years. They aim to make therapy more accessible and announced about two weeks ago that psychotherapy centres, to which patients will be referred directly, would be established in all primary care trusts. This will involve training 3,600 more psychotherapists. However, it takes about four or five years for them to become competent and the problem is more urgent than that; we do not have the time to train that many people.
The rather irritating fact is that the Government have had a partial solution at their disposal for some time in the form of computerised cognitive behavioural therapy. This, I emphasise, is useful for mild to moderate depression. At this juncture, I declare that I have absolutely no financial interest whatever in any company that provides software for these therapies.
In February 2006, NICE recommended that primary care trusts should purchase and use computerised CBT, and a treatment called “Beating the Blues” was recommended. It should have been available 90 days after recommendation; primary care trusts are obliged to provide their patients with what NICE recommends. It would treat 400,000 people each year, producing a cost benefit to the NHS of £126 million a year. Despite this, there has been only about 15 per cent take-up by the primary care trusts. To date, nine primary care trusts have complied with NICE guidance. It is another NHS treatment at the mercy of the postcode lottery.
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Many who have used “Beating the Blues” have found it very helpful in dealing with their problems. The Government have failed too many people who are suffering. The problem of depression is immediate and requires treatment now. The Department of Health has been offered a way by NICE, which approved “Beating the Blues”, to treat people as part of its access to psychotherapy programmes, but it has failed to take up the recommendation.
Ministers have given all sorts of assurances over the years. In March 2006, the White Paper Our Care, Our Health, Our Say included a commitment to support primary care trusts in delivering these computerised treatments. In November 2007, the national director for mental health, Louis Appleby, wrote to all primary care trusts reminding them of the obligation to provide computerised CBT by 31 March 2007. On 28 March 2007, Patricia Hewitt, then Secretary of State for Health, told us that patients would have this service provided by their primary care trust. In December 2008, only a few months ago, Health Minister Dawn Primarolo said that primary care trusts were obliged to provide funding for NICE-recommended computerised CBT packages.
So where is it? Why is it not being delivered? We get more and more announcements and commitments to mental health services, but this promise is yet to be delivered three years on. Alan Johnson has tried to be helpful by saying that patients who are dissatisfied with the non-availability of a treatment should take up their concerns through the NHS complaints procedure. In my opinion, an already mildly depressed patient might become very seriously depressed or even suicidal if they had to tackle the NHS complaints procedure. I had plenty of experience of that with my constituents in the other place.
The trouble is that government promises are not being delivered—period, as Tony Blair used to say. I appreciate that, in some sections of the profession, it will be said that a computer program cannot replace a face-to-face session with a trained psychotherapist. Maybe not, but it can replace a non-existent psychotherapist, which is currently the reality for most patients with mild to moderate depression.
This should not be a consideration in clinical treatment, but it is worth remembering that, in 2004, the noble Lord, Lord Layard, in his paper Mental Health: Britain’s Biggest Social Problem?, estimated that the cost then of a course of face-to-face CBT was £750, whereas, according to NICE, the computerised program that that body had approved cost £45. That is a huge difference. Help could be made available to far more patients. We must also remember that many young people who suffer from depression spend an awful lot of time with their computers. My young people certainly do; I sometimes think that Facebook has replaced the pub for some of them. We may sneer, but it is the most natural thing in the world for them to talk to a computer.
In conclusion, we cannot wait any longer for evaluations and reports to see whether greater access to CBT is being achieved for patients with mild to moderate depression. There is a proven treatment, but it is still not available in the vast majority of primary
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care trusts: computerised cognitive behavioural therapy. In the current economic downturn, more and more people will be affected by depressive illness. It could be any of your Lordships.
My colleague in the other place, Norman Lamb, has tabled an Early Day Motion on computerised CBT, which over 50 MPs have already signed—20 from the Minister’s own party. I look forward to the Minister’s assurance that she will rectify this problem and make the treatment available in all primary care trusts.
Lord Layard: My Lords, this debate is extremely timely; I congratulate the noble Baroness on having introduced it. It is timely because of the recession that is now upon us, and which will do so much damage to the mental health of so many citizens of this country.
The goods news is that the Government, well before the recession was even dreamt of, had embarked on the programme to which the noble Baroness refers, which will revolutionise the availability of psychological therapy services in this country. I do not think that any of us are opposed to computerised CBT, as recommended by NICE as part of the stepped-care system; of course, it is one of the rather low steps. It has also required the participation of a living therapist for it to be effective in any of the evidence-based trials. For anybody with a serious condition, the human one-on-one treatment is essential. That is what the Government’s programme concentrates on.
In a debate on the future of CBT in this country we must focus mainly on CBT provided by live therapists to patients in the new way that the Government will make possible in this country. This is the most radical improvement in psychological therapy services ever undertaken. I am impelled by the fact that we are having this debate to say a little about some of the good things about it. I should declare an interest because I am a member of the programme management board. However, I then want to say a bit about its future, which is still not assured, because it depends on the upcoming Comprehensive Spending Review. Then I would like to say something about CBT for children, which is also a very major issue that still needs to be addressed properly.
Let me start with the scale of the problem, which the noble Baroness mentioned. Sixteen per cent of the adult population suffer from clinical depression or a diagnosable anxiety condition. Until now the main support available for these people has been non-specialist support from GPs, mainly in the form of medication. This is despite the NICE guidelines, which say that computerised CBT should certainly be available in the early stages, but also that one-on-one CBT should be available for everybody who suffers from depression or anxiety disorders that are not either very mild or very recent. As has been said, that has not been the case throughout the country, due simply to the fact that the therapists have not been available within the NHS to deliver it.
However that all changed from the announcement that the Secretary of State made in October 2007, when the Government committed themselves to creating
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a modern psychological therapy service throughout the country that delivered the NICE guidelines to everybody who needed them. This commitment was backed by the full amount of money that had been estimated as necessary and feasible over the CSR period that followed on from that announcement. We now have this programme of improved access to psychological therapy, or IAPS, which is being rolled out throughout the country. It is led by an excellent team in the Department of Health and it is very clearly described on its website. To give the bare bones: in the next three years, as the noble Baroness said, the plan is to train 3,600 new CBT therapists, not through five-year courses—because these will be people who already have experience of working with mentally ill people—but one-year courses involving a combination of off-the-job training and on-the-job supervised cases. All the professionals believe that that is what is needed to enable somebody to be a professional CBT therapist.
The programme of training and rollout started in October and it is running well ahead of schedule. In two years from now over half the people in the country will have access to it, because of the grass roots enthusiasm which the primary care trusts have shown in responding to this challenge. I would just like to put in parenthesis that the pushing of computerised CBT preceded this programme, and was based on the assumption, to some extent, that this money would not be available. The noble Baroness has an important point about computerised CBT, but we have to realise that this programme supervenes the instructions that were given about that, and delivers hope of something much more serious than the computer can deliver.
How do we know that all this rollout is worthwhile? We know from randomised control trials, which show that at least half of those treated will recover from their conditions as a result of treatment. Pilots in the field have confirmed this success rate, and of course that means that not only will we get major humanitarian benefits from this programme, but we will also get—and we can do these calculations—a return to the Exchequer which would fully repay, in savings on benefits and lost taxes, the expenditure that is being made. So it is very important that we proceed with this programme at the centre of our effort to deliver CBT to the British population. We will know whether it is working because every session that a CBT therapist has with a patient will include monitoring the patient’s progress. This will not be money down the drain.
The problem is that the programme is funded for three years but after that there is no commitment. We are just coming up to the spending round in which that will be determined. It is vital that the programme continues until the whole country is covered, not just half of it, by these state-of-the-art services. We have therefore to ensure that in the next spending round the necessary growth in funding continues from 2011-12 onwards. We owe that to the people out there who are suffering.
In the pilots, the typical patient treated had been suffering from their condition for five years—five years of wasted life, when they could have had, with a 50 per cent probability, a complete transformation of their lives. We cannot allow that to continue. So I have a
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simple question to the Minister. Can she assure the House that when the department compiles its spending bid it will indeed seek the funds necessary to complete this crucial programme?
I should like finally to say a word on children. The programme that I have been discussing relates to adults, but of course many of those who suffer as adults also suffered as children. Child mental illness is even more tragic than for adults. It is also the source of so many of our social problems. Ten per cent of all children would be diagnosed as suffering from mental illness of all kinds, and 5 per cent from anxiety disorders for which the prime treatment is CBT. Of these children only a quarter are currently receiving specialist help or have seen a specialist in the past year. That is just not good enough. Although we have child and adolescent mental health services which in many cases are excellent, their capacity is just too small. There are many children in real need who get turned away or do not get referred because the waiting list is too long, and not all the services are delivered in accordance with the NICE guidelines.
What we now need is a strategy for expanding and upgrading CAMHS as well as adult services. A number of us have suggested a five-year plan which would train 200 extra child therapists every year and be adequately funded to pay local services for providing the on-the-job training within the NICE guidelines. I think that that would be a powerful formula. It would cost no more than £35 million by the final year of the next spending round. I very much hope that the Minister can undertake that these proposals will be seriously considered for very high priority in the department’s spending bid.
To conclude, we have an excellent plan for providing face-to-face CBT—obviously, computerised CBT will be there as well—to all adults who need it, but it still needs to be refinanced for the second half. We need to do something similar for children. I have every hope that the Government will do this because they have shown their willingness to bite this bullet which had been neglected for so many decades. This Government have been outstanding so far in their approach to this, after decades of neglect. I really hope that they will complete the job.
Baroness Meacher: My Lords, I welcome this debate initiated by the noble Baroness, Lady Tonge, but I begin by applauding the Government on the considerable progress that they have made so far in extending the availability of CBT across many parts of the country. Improved Access to Psychological Therapies is bringing CBT and other NICE-recommended treatments to millions of depressed people and people suffering from anxiety, most of whom have never had access to any psychological therapy in the past. That is an important point, because a number of NICE-recommended treatments are included within the programme. As others have commented, this is the most significant development in mental health since the inception of the NHS. It is pretty powerful stuff. The IAPT programme is placing this country in a leadership role internationally in the delivery of psychological therapies.
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My noble kinsman Lord Layard, as I think I have to refer to him, spoke about CBT itself, and I want to limit my remarks to the computerised version of that programme. Before doing that, I should briefly mention that I have an interest in this as chair of the East London NHS Foundation Trust. We happen to have one of the two pilots in the CBT programme and it was very moving to listen to a number of users talk about having direct access to this programme. They did not have to wait 18 months; they could walk in, self-refer and have access to CBT. They talked about how much better they felt and the fact that they now had jobs. Things really are happening on the ground which we can be very pleased about.
I want to be clear that when referring to computerised CBT I am referring to all the versions of it. I was a little distressed that the noble Baroness, Lady Tonge, mentioned only one such version, and I fear that she may have been at the receiving end of some pretty effective marketing on behalf of a commercial company, because there are a number of computerised versions. The commercial product is called Beating the Blues, which was recommended by NICE in 2005. More recently other programmes have been reviewed and encouraged by NICE, which regards them as comparable to and as good as Beating the Blues. The dramatic difference between Beating the Blues and the other computerised programmes is that these others are free of charge, whereas the licence fee for Beating the Blues is £30,000—not an inconsiderable sum.
These programmes can be used for primary treatment; alternatively, they can be used to add value to a therapist-delivered programme where the therapist’s work is the core treatment. The research evidence quoted by NICE suggests that the computerised programmes can be helpful in either situation, given a professional therapeutic environment.
The only really important point that I want to make is that computerised CBT can only be effective if it is delivered in a therapeutic environment and is supported by about three sessions of face-to-face CBT. These programmes should not, therefore, be delivered without that support, nor only with the support of a Beating the Blues member of staff, who are not actually trained to Department of Health standards. This is fundamental. The best way to ensure benefit to the user is for the patient to access a computerised CBT programme at a recognised IAPT site where they can be sure that the support therapists are properly and appropriately trained. The only cost per patient using a free programme is between £17 and £36 for two or three hours of a low-intensity worker at band 4 or 5.
The significant impact of input by trained therapists was well illustrated by a recent study of the computerised treatment of social phobia. Only 33 per cent of patients completed a course of stand-alone treatment without any therapist input, whereas 77 per cent of those receiving clinician support as well as the computer programme completed the treatment. The conclusion of the research was that the clinician-supported programme was a success and the non-supported programme was not in any significant way.
Why am I so concerned to ensure the availability of therapeutic support from a properly qualified person if a patient is using computerised CBT? It is common
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sense. If a patient has a problem with CCBT, they become disillusioned. One should remember that these people are already depressed or perhaps very anxious. As a result, if they are subsequently offered the real thing—CBT face to face with a therapist, or group CBT—they are likely to turn it down, assuming that it will be just as bad as the treatment they have tried. We know that 50 per cent of people with depression can be cured by CBT: that is a very powerful statistic. It would be a tragedy if many of those people, having tried something in the wrong way and with inadequate support, then turned their back on their one hope of a cure.
Baroness Tonge: My Lords, I am extremely interested in, and overwhelmed by, the noble Baroness’s knowledge of this subject. However, I have seen the reverse situation apply, which is why I was so enthusiastic about the computer system. Many patients see a behavioural therapist and do not get on with them: the therapy does no good, or they do not like having to go and see somebody or to take time off work. They are greatly advantaged by the computerised system.
Baroness Meacher: My Lords, one interesting aspect of the two pilots of the new IAPT system was the use of the telephone in the Doncaster pilot. We have all learned a lot from that experience. Some people do not want face-to-face therapy. However, having a professional therapist working with you over the phone is very different from working with a computer, on your own and unsupported, feeling depressed and trying to manage. Having lost my speech on my flipping computer this evening, I say with great feeling that the frustrations caused by a computer can be considerable.
These are complex matters, but the evidence suggests that it is very important to have a well trained professional with you at the beginning of your treatment, so that when you start using your computer, the therapist can check that you are getting along okay, are happy with it and making progress. We do not want people buying a very expensive product and starting the programme without the necessary support. Not all of us are computer-literate. I like to think that I am half-computer-literate, but many people are not even that. Workbooks can be given to people, in which the treatment is the same as the computerised CBT, but the words are on paper instead of on a screen. All the options can be weighed up by a professional therapist who understands the different treatments available, and can judge what will suit each patient.
That is what we need to work towards. What we must be careful about is something that does more harm than good. There is no question that a stand-alone computer programme can do more harm than good to many people, by blocking them from a treatment that could be much more effective.
I look forward to hearing what the Minister has to say. I hope that she will assure the House that, for the treatment of depression, every PCT will be encouraged to make available computerised CBT—ideally the free version, but certainly some sort—along with the face-to-face and group treatments involving CBT techniques.
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Lord Rea: My Lords, I thank the noble Baroness, Lady Tonge, for asking this very interesting Question. I am sorry that her noble friend Lord Alderdice was not able to stay on the speakers list, because I should have been very interested to hear how he, as a consultant psychotherapist, viewed this subject.
I am also delighted to have heard the double act that we have just experienced. Both noble Baronesses and the noble Lord, Lord Layard, are singing from the same hymn sheet—at least, they are in harmony—but, in comparison, I shall strike a slightly discordant and rather more cautious note. As noble Lords might expect, I shall speak from the perspective of a former GP.
Large numbers of studies testify to the very high proportion of consultations in primary care that are due to psychological problems. Some estimates are that they account for up to 50 per cent of a GP’s work. Although only about 10 to 15 per cent of the population on a GP’s list may have a long-term identifiable psychiatric illness, those people consult much more frequently than the average. At any one time, a similar proportion of the psychologically “normal” members of a GP’s list have transient problems in reaction to a particular life stress: bereavement, relationship breakdown and now, as all noble Lords have said, job loss, possibly repossession of a house or bankruptcy. Often, psychological distress is expressed indirectly in physical symptoms or in consultations for self-limiting afflictions which more robust people would shrug off. Sometimes anxiety about physical symptoms without demonstrable cause can be allayed only by a hospital referral. Thus, many specialist out-patient clinics also contain a high proportion of anxious or depressed patients. Often, a negative X-ray or blood test, for example, is needed before the patient, and sometimes the doctor, can accept that the problem is psychological or emotional rather than physical.
However, part of the reason for the apparent increase in stress-related disorders is that it is now more socially acceptable to speak about them and to seek help. It is also now recognised that more physical symptoms may have a psychological explanation than was previously thought to be the case. However, while some of these symptoms can be relieved by suitable medical drugs, the patients are likely to relapse when the treatment stops if the problem is long term. There are also unpleasant side-effects, and dependence is common, especially with the benzodiazepines.
Medication is of course a tempting option when consultation times are short and psychological treatments are rare, but the benefit is temporary unless psychological or talking therapy is also given by either the doctor or another person. Medication does not touch the root of the problem—it has been described as “sweeping the dirt under the carpet”—but it can often be useful at the beginning of a course of psychological treatment. For example, if a client is too depressed to engage with the therapist, he or she may need a small pharmacological boost to begin with. However, I think that all noble Lords here accept that there is a real need for psychological therapy in both primary and secondary care. As all noble Lords have said, it is good that the Government
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have recognised the value of psychological treatment through initiating IAPT. I point out that this initiative is not restricted to CBT but includes different modes of psychological treatment, as well as counselling, which in good hands can be effective in many cases and is now frequently what we fall back on.
CBT, as we now always call it, has gained in importance partly because it lends itself to assessment much more readily than other therapies. It is of limited duration and predictable structure. A large number of case control studies have been carried out on CBT which have shown its usefulness and, in some cases, its cost effectiveness compared with medication. The methodology of some of these studies has been criticised. However, NICE, which has a reputation for insisting on sound research, has recommended CBT including CCBT, as other noble Lords have described, in that programme, Beating the Blues for depression in children and a for number of adult conditions. However its effectiveness compared with other forms of psychotherapy is not so well documented—at least according to my rather limited search when preparing this speech.
A comparable and more ambitious form of brief psychotherapy is CAT—cognitive analytic therapy—developed by Dr Anthony Ryle which consists of, rather similarly to CCBT, 16 sessions and aims at reformulation of a person’s relationships with the important people in their life history, thus increasing understanding as well as altering behaviour. Both clients and therapists in that treatment have to work harder than in CBT, which is popular with clients and therapists alike partly because it has a readily understandable structure and does not probe too deeply into uncomfortable areas. It helps clients to devise coping strategies for their symptoms and maladaptive behaviour, but it does not attempt to help them to understand fully the origins of their difficulties.
One problem with behavioural therapy—cognitive or otherwise—is that while it is often very effective in eliminating symptoms or compulsive behaviour, for instance, other problems tend to crop up later because the underlying problems have not been addressed. Psychiatrists have suggested to me that while it can be useful in itself, it is a good non-threatening introductory route into more in-depth psychotherapy for those who need it. Others have been less kind and describe it as a quick fix—possibly pushing the dirt aside rather than, as drugs do, sweeping it under the carpet, but nevertheless not clearing it away. That task is of course sometimes not attainable with any form of therapy. Some, who are even less kind, have let off broadsides against it. Professor David Richards, professor of mental health at New York University and a one-time proponent of CBT, said in a recent paper:
“It is an unproven contention that it is possible to take the results of experiments conducted by charismatic product champions, in highly controlled environments and implement them in the widespread manner suggested by Layard”.
Sometimes I am thankful not to be in the stimulating atmosphere of the academic world.
Lord Layard: My Lords, there have been field trials, including the two in Doncaster and Newham, that have found exactly the same results as those in the more rarefied clinical trials to which the American professor referred.
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Lord Rea: My Lords, I thank my noble friend for that explanation. CBT is popular at the moment, but I am sure that my noble friend will agree that the Government should not put all its eggs in one basket. The Royal College of Psychiatrists and Royal College of General Practitioners last year produced an excellent joint report on Psychological Therapies in Psychiatry and Primary Care in which all forms of psychological therapy are considered. One recommendation which I like is that all organisations providing psychological help should “promote psychological mindedness”. This certainly prevailed in the health centre in which I worked to the benefit of both patients and staff. The Government would be well advised, if they have not already done so—it is likely that they have—to take full note of this report and act on its recommendations.
The Countess of Mar: My Lords, from my point of view it is wholly appropriate that this subject should be debated at this time and I am grateful to the noble Baroness, Lady Tonge, for her introduction. I declare my interest as chairman of Forward-ME and as patron of several ME charities.
While I recognise that there are some patients with a variety of conditions apart from mental illness—cancer, for example—who might benefit from cognitive behaviour therapy, or CBT, as it is known, I would like to introduce another note of caution. The noble Lord, Lord Rea, has already introduced his. CBT is not the cure for all ills that it is sometimes held up to be. Indeed, it is not, strictly speaking, a treatment at all, since its purpose is to support patients in recognising and managing their symptoms. However, there is a group of chronic illnesses where overwhelming post-exertional fatigue is a major factor, causation is poorly understood, and for which there is no single or comprehensive treatment—CFS/ME, fibromyalgia and irritable bowel syndrome, for example—that do not respond positively to CBT. Patients expect doctors to provide answers, and doctors are, naturally, reluctant to admit defeat. Current advice to doctors is that, after routine tests have failed to point to causation, there is no need for further investigations. Some doctors take the easy route by concluding that the illness must be psychological and that CBT will provide the answer. However, many clinical tests listed in the Canadian criteria do show disease/disorder dysfunction in many bodily systems.
I will deal only with the 240,000-odd CFS/ME sufferers this evening. This is an illness that, according to some researchers, has had several different names in the past; neurasthenia and hysteria are examples. Others researchers have believed since 1934 that it is caused by viruses, other micro-organisms or toxins. Even more confusing is the incidence and severity of symptoms reported by patients. It is not surprising that almost everyone concerned with this illness, be they patient, carer or medical practitioner, is, to some degree, bewildered.
In the face of this bewilderment, in 2004, the Secretary of State for Health and the Welsh Assembly asked NICE to prepare,
“guidance on the assessment, diagnosis, management of adjustment and coping, symptom management, and the use of rehabilitation
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strategies geared towards optimising functioning and achieving greater independence for adults and children with CFS/ME”.
In August 2007, the guideline was published amid a barrage of criticism from the ME community. Why was it criticised? It was because the only “treatments” recommended by NICE on the basis of very limited and strongly criticised scientific evidence were CBT and its twin sister, graded exercise therapy or GET. The quick reference guide to the 300-plus pages of the full guidelines described CBT as:
“An evidence-based psychological therapy that is a collaborative treatment approach. When it is used for CFS/ME, the aim of CBT is to reduce symptoms, disability and distress associated with the condition. The use of CBT does not assume that the symptoms are psychological or ‘made up’”.
Unfortunately, in the view of a number of professional organisations and researchers working in this field, the evidence-base is not as clear as NICE would have us believe. A statement from ME Research UK asserts that:
“The evidence base consists of only five trials which have a validity score of less than 10. We note that the most recently published RCT on CBT (O’Dowd 2006) states: ‘there was, however, no evidence that the treatment restored normal levels of function for the majority of patients’”.
The Association for Psychoanalytic Psychotherapy in the NHS states,
“it is highly misleading to state that CBT is the therapy of first choice, since the only relative efficacy RCT quoted in the Guideline (Risdale et al 2001) shows that counselling has better outcomes than CBT”.
It goes on to say that:
“This recommendation seriously conflicts with the recommendation that patient choice and preference need to be uppermost in the collaborative approach to care, and the finding that 45% of patients report either being made worse or not helped at all by CBT and, elsewhere, only 7% of patients surveyed report being helped”.
“Why is a misleading recommendation being made?”.
There is no mention in the NICE guidance of the analysis report in 2004 by the 25% ME Group for Severe Sufferers that was submitted to the GDG of NICE that reported that 93 per cent of respondents found CBT unhelpful.
I could cite a great many more criticisms of the recommendation by NICE for CBT. The recent judicial review did not test the scientific validity of NICE’s recommendation for CBT and GET. The statement issued by Professor Littlejohns, NICE clinical and public health director, that the decision,
“means that the NICE guideline is the gold standard for best practice in managing CFS/ME”,
is not entirely accurate.
People with ME already bear a great burden of disbelief about the reality of their illness from their closest relatives, their friends, the medical profession and other care professionals they encounter, as well as the community at large. There has been a preponderance of articles on “yuppie flu” in the press and broadcast media; research funding, other than that provided by the ME charities, has been exclusively weighted in favour of the psychosocial as opposed to the biomedical aspects of the illness; and ME patients seem to have to
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go through a great many more hoops, including CBT, to obtain and retain social security benefits and social care packets, as well private health insurance.
I have a quotation from Health Insurance News UK dated 22 February 2009. Under the heading,
“Medical Insurance May Not Cover Chronic Fatigue”,
it gives a condensed description of ME. It then states:
“This sounds like a physical problem, doesn’t it? However, the NICE guidelines suggest that it is a psychiatric condition rather than a physical one.”.
It goes on to say:
“Because of the NICE guidelines private health insurance companies are within their right to refuse cover if an applicant’s policy does not include psychiatric cover”.
I cannot find any confirmation for the extraordinary suggestion that ME is a psychiatric condition in the NICE guidelines. Will the Minister ensure that this misinformation is rapidly withdrawn?
Young people with ME get very little understanding of their predicament from educationalists and social workers. Far too frequently their parents are accused of “perpetuating the child’s illness behaviour”. This often results in the child being put on the at-risk register, forcibly removed from the family and given medical treatment, including CBT and GET, that commonly does not work. The child is then blamed for the failure. It can then take years for the child to regain any semblance of a normal life. Too many children remain isolated and ignored and living in a twilight world.
I have been dealing with ME sufferers for 17 years and I have never encountered a group of patients who are so maligned. The last straw for them is the requirement that they undertake a course of CBT and/or GET in order to qualify for benefits and private insurance payments. I accept that, in some cases, CBT alone may be beneficial. I suspect that in the old days it would have been called “grin and bear it”. However, CBT is rarely offered without GET and ME patients know only too well—and their views are supported by some 4,000 papers on scientific and clinical research—that GET makes their symptoms worse.
The NICE guidelines lay great stress on the importance of shared decision making, working in partnership with the patient and the need for specialist expertise. Unfortunately, because this is a “Cinderella” condition, there are few specialists. Indeed, some of the specialist centres set up following the CMO report in 2002 have had to close because of a lack of funding and expertise. For this reason, “referral out of area” and “choose and book” should be available to all sufferers.
The Department of Health and the World Health Organisation acknowledge that this is not a psychiatric condition. What action is the Minister’s department taking to ensure that people with ME are as respected as people with other medical conditions and that they are not forced to accept, as a condition for receipt of benefits and social care, “treatments” such as CBT and GET that, at best, provide no beneficial effects and, at worst, are positively harmful?
I remind the Minister NICE guidelines state:
“Healthcare professionals should be aware that—like all people receiving care in the NHS—people with CFS/ME have the right to refuse or withdraw from any component of their care without this affecting other aspects of their care, or future choices about care”.
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Lord Carlile of Berriew: My Lords, I declare two interests: the first as a patron of a small but fascinating charity in the West Midlands called No Panic; and the other as president of the Howard League for Penal Reform, which deals with and advises many people who suffer from mental illness while in custody. I congratulate my noble friend Lady Tonge on asking this Question and securing this debate on a very important subject.
There is nothing new about CBT, except perhaps the label and considerable sophistication of techniques. Were he still living, my father would now be 104 years old; he was a general practitioner in an industrial Lancashire town. Despite having spent two years of his high school education in Vienna, he generally regarded psychiatrists as a visitation of the devil. However, he spent an awful lot of his time talking to his patients and we, his children, were there because we lived in the surgery; we lived his life with him. He used to say, as advice for our future, “Just remember: people who don’t eat want to eat, people who can’t go to school want to go, people who are completely unable to work because of a mental condition really want to go to work, and those in that terrible category of agoraphobics want to go out and enjoy life. It is just that they can’t”.
The therapies that my father, and many old-fashioned general practitioners, applied in such places when the local economy and culture collapsed—when the cotton industry was destroyed, and people were suddenly putting together gas cookers rather than enjoying the camaraderie of the cotton mill—all contributed to his powerful belief, which he certainly instilled in his children, that talking to people about their problems helps an awful lot, and probably a great deal more than pharmacology. A starting point in any discussion of mental illness is, surely, that it must never be regarded as a second-division form of illness.
The noble Lord, Lord Layard, has made a great contribution to the argument in that mental illness is an illness like any other, and needs to be treated with the same serious attention. We know, because we all have friends and relatives who have suffered from depression and other mental conditions, that it knows no class distinction, belongs to no one political party—it probably belongs to them all—and sees wealth as no barrier. There is no quick fix. We should not wed ourselves to any one solution. The old-fashioned Jungian/Freudian divisions are to be avoided in CBT, as in anything else. We have to make the best of the cocktail of cures that is available—on a subjective basis, of course.
Anyone who has ever been close to a seriously mentally ill person, whether they are suffering from phobia, depression, an eating disorder or anything else, knows how tempting it is to think and sometimes, foolishly, to say, “Oh, just pull yourself together and get on with life.” However, before they reach anything like a “pulling themselves together” situation, people suffering from mental illness, like people with serious physical illness, need something and/or someone else to pull them together sufficiently to progress to full recovery. Between wanting to be better and starting to be better, there is a large space where cognitive behaviour therapy has an important role to play.
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We must also not forget the cost of failing to deal early with mental illness. It merits repeating again and again that it has a terribly high mortality rate. The mortality from most illnesses is at the hands of the illness; the mortality from mental illness is usually at the hands of the sufferer. It produces frequent self-harming scars that stay with the sufferer for life, a refuge in dangerous substances, and a reduction in revenue through inability to work. For some, as the Howard League knows only too well, it produces incarceration in prisons and young offender institutions. Shockingly, about half those incarcerated there are suffering from diagnosable mental illnesses, but many are not being treated for them. This is no exaggeration of the morbidity of recognised and easily diagnosable conditions; it is a fact.
What does CBT offer? Not a miracle—it may be completely wrong for some cases—but it at least offers cheap, early intervention. There is plenty of evidence, for example, that early, non-pharmacological intervention in teenage anorexia and depression, which destroy many young lives and hold those people back for years, can result in total recovery and a successful adult life. There is evidence, too, from those GP practices around the country that have very imaginatively taken on talking therapy psychotherapists as part of the apparatus of their practices that the recovery of patients is quicker, less reliant on drugs and less liable to secondary and tertiary referrals. The recent Royal College of Psychiatrists study by Muñoz-Solomando, Kendall and Whittington, provides powerful and peer-reviewed support for the use of CBT in many child and adolescent mental health cases, including cases of OCD, post-traumatic stress disorder and even attention deficit hyperactivity disorder. The evidence from that study is that when people are in groups, when they are able to talk to each other with the guidance of a psychotherapist using CBT techniques, recovery can be hastened dramatically.
NICE was absolutely right in recommending, as the first line in child and adolescent mental health, that there should be non-pharmacological approaches. I respectfully agree with the noble Lord, Lord Layard, that there are great merits in this and that there is evidence of such a programme being rolled out. However, I share the view of my noble friend that it is being done too slowly and that it should reach the outer reaches of this country as quickly as possible. I shall say a word about rurality in a moment.
There is remarkable evidence that a combination of CBT and Fluoxetine, a tried and tested substance, appears to reduce the risk of self-harm for depressed children and adolescents. So the news that CBT sends out is good. It is so good that I offer one plea to the Minister to which I hope she will respond. There should be far more of it in prisons and young offender institutions. Those are places where it can be tried, tested, made available and used on an everyday basis. You are guaranteed the co-operation of the patients: they are captive—they have nothing else to do, they have no choice. What better cohort to cure than people who are already costing us at least £45,000 a year to keep in custody?
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This presents the most remarkable value against hospital admission. I went to a hospital a couple of years ago where I was told that a seriously ill adolescent with a mental health problem was costing up to £145,000 a year to keep in hospital. It is probably a good deal more now. Early intervention might avoid some of those cases.
This provision should be made available throughout the United Kingdom. I know that the Minister does not have responsibility for Scotland and Wales. I have an interest in Wales because I used to sit in the other place for a Welsh constituency. The availability in rural parts of England, as in rural Wales, is very limited, particularly when there is a great need for the therapies to be given by people qualified to give those therapies and not others. Occupational therapists are not necessarily very good at psychotherapy, and vice versa. It needs to be accurately targeted and used.
Rural areas are very neglected in mental health provision, but there is plain evidence of need. I have a niece who runs a charity for the Church of England which deals only with depressed and suicidal farmers. They are just an example of a cohort living in the countryside, often very isolated, which needs to have this sort of therapy available. I applaud the computerised version of this therapy; it has a great deal to offer, although I do not think we should spend a huge amount of time on it because it is a small part of a big subject.
My final plea is this: let us keep mental health provision above party politics.
Baroness Verma: My Lords, the noble Baroness, Lady Tonge, has given us an opportunity to raise a range of serious questions. Through my business in the care sector—I declare an interest—my staff constantly face people suffering mental health issues.
We are all aware of the debilitating effects that depression, chronic anxiety and other matters related to mental health can have on our ability to carry on with our lives as normally as possible. We are also aware that many people are affected by some form of mental health issue in their lifetime. I shall repeat and reflect on many of the remarks made by the noble Baroness, Lady Tonge, and other noble Lords.
NICE has recommended psychological therapies for people with a range of mental illnesses, but reports show that 86 per cent of people with schizophrenia are still not getting any treatment. We all agree that psychological therapies are not a one-size-fits-all solution, but for many people there are clinical benefits and, in the long term, there is a cost saving to the Government. NICE recommends CBT as the treatment of choice for people suffering from post-traumatic stress disorder, OCD, bulimia nervosa and clinical depression.
As the noble Baroness, Lady Tonge, said, evidence shows that the number of cases of mental illness and suicide increases with rises in unemployment, repossession of homes and uncertainty about the future. All these factors have a huge impact on how families and communities cope. Researchers have calculated that we will therefore see a rise by at least 26 per cent in the
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number of people suffering mental disorders by 2010. That is 1.5 million more people with mental health problems in England.
In light of his predicted rise in the number of people suffering from some form of mental health problem as a consequence of the recession, how many cognitive therapists on top of the promised 10,000 do the Government expect will be needed and what are the Government doing to meet the shortfall?
In 2008, 141,000 people claimed incapacity benefit for mental health-related illnesses. Government research shows that 69 per cent of those people were unable to access occupational health through their employer while in employment. What are the Government therefore doing to ensure that employers are aware of initiatives that could help people with mental health problems in their employment? How much money has been spent on providing this resource?
How many people have been treated with CBT since 2006 and is there any information to show the cost benefit to the health service? Phil Hope said in another place that,
“there will be significant cost savings to the national health service by implementing Improving Access to Psychological Therapies services by reducing pressure on specialist psychology services in mental health trusts and reducing inappropriate referrals made to acute hospital trusts for people with medically unexplained symptoms”.—[Official Report, Commons, 24/11/08; col. 909W.]
How much will the Government have spent on implementing IAPT by 2011?
If primary care trusts are obliged to provide funding for NICE-recommended computerised CBT packages where clinicians want to use them but decisions about care provision are made by individual PCTs, what are the Government doing to end the postcode lottery of access to computerised CBT services and so enabling access for the rising number of people who want them?
While we recognise the benefits of CBT, without adequately trained psychologists, psychotherapists and nurses, it will be impossible to meet any government targets for service provision. The Government recognise that an extra 10,000 therapists are needed, so can the Minister say when they anticipate reaching this target? Are there figures to show the ratio of people with GP-diagnosed mental health problems to therapists in each PCT area? I ask because it is estimated that PCTs have purchased only 15 per cent of the treatments required. Meanwhile, people are put on lengthy waiting lists at a cost of around £300 million per year. How many people are on the waiting list for cognitive therapy in each PCT and how many are receiving treatment? How many community mental health teams in each PCT offer CBT?
I shall turn briefly to children. One in 10 of all five to 16 year-olds have some clinically significant mental health difficulty. Sadly, only one-quarter of them receive specialist help. What are the Government doing to act on the recommendation of the report A Good Childhood that IAPT is rolled out for all children as well as adults?
The debate cannot have a narrow focus on whether therapy works or not. It is widely recognised that there will be those who do not benefit from CBT. However,
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in evidence to the Health Select Committee in March 2007, Professor Michael Barkham recommended that the Department of Health should work with NICE and professional bodies in psychological therapies and agree a national research programme. Will the Minister say whether those recommendations have been followed and whether the Government have undertaken randomised controlled trials of alternative forms of therapy since 2007?
This is a subject that demands a raft of questions and of course recognition that different people need different treatments. Unfortunately, time is not on our side. I would very much like to hear the Minister’s response to the questions raised in this interesting debate.
Baroness Thornton: My Lords, I congratulate the noble Baroness on her success in securing this debate on such an important and timely subject as psychological therapies. This is a matter in which my right honourable friend the Health Secretary has taken considerable interest in the last few years.
The Improving Access to Psychological Therapies programme is the focus of major investment by both the Government and the NHS. My right honourable friend Alan Johnson announced annual funding rising to £173 million—that is the first question answered for the noble Baroness, Lady Verma—by 2010-11, to improve the care on offer to people suffering from depression and anxiety disorders. This investment was warmly welcomed by all the major charities representing people who use mental health services, as well as the key professional bodies of psychological therapy practitioners from a wide range of disciplines. I pay tribute to my noble friend Lord Layard for his important work in this area; his remarks were welcome and positive, and we know that he is watching us in this matter. I take his point about funding issues; in many ways, I was rather expecting the noble Baroness, Lady Tonge, to berate me about such matters, too.
The overall aim of this investment is to help the NHS implement guidance from the National Institute for Health and Clinical Excellence—NICE—relating to effective evidence-based treatment for depression and anxiety disorders. The guidance outlines appropriate treatment arranged in a series of steps. Each step relates directly to specific and measurable levels of depression or anxiety disorder. Each step offers clinicians a number of effective treatment options, which a practitioner and a patient will discuss and agree on the most appropriate.
Computerised CBT, specifically Beating the Blues, is one of the indicated treatment options for people with mild depression. However, NICE is currently in the process of reviewing its guidance on the treatment of depression and recently published a consultation document which broadens the range of effective computerised CBT programmes to include many that do not incur a cost to the NHS.
Baroness Tonge: My Lords, could the Minister tell me, before she goes on, why the original computerised CBT approved by NICE had so little take-up when the need out there was so desperate?
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Baroness Thornton: My Lords, it might have been the cost. It is vital that people using computerised CBT are supported by trained therapy workers; it could be that it was a question of putting together packages. Evidence shows that it is ineffective if no trained support is given. My noble friend Lord Layard outlined the issue concerning CBT much more eloquently than I did, and was supported by the remarks of his noble kinswoman.
I take issue with the idea that this is a postcode lottery. This representation of how NICE guidelines work is incorrect; the current guidelines mean that PCTs have to make Beating the Blues available if their clinicians prescribe computerised CBT for their patients. If clinicians in consultation with individual patients do not prescribe computerised CBT, clearly there will be no need for the PCT to provide it. So there is no more a postcode lottery here than in any other choice between recommended treatments. There is consultation between the clinician and patient.
To provide the full range of NICE recommended treatment options, the programme will initially train a new workforce of 3,600 therapists. Initially, this training will focus on cognitive behavioural therapy and the routine collection of patient-reported outcomes at every session. In November last year, we published our statement of intent to broaden the programme’s approach, working towards ensuring that all patients have a choice of evidence-based psychological interventions by extending the skills of these new therapists as the services mature.
The programme was initially piloted in Doncaster and Newham, as noble Lords have said. Both areas succeeded in dramatically cutting waiting times and brought half the people they treated to measurable recovery. They also increased the number of patients who were in work by 5 per cent. The pilot sites demonstrated success in reaching and providing effective treatment to previously hard to reach groups.
The NHS has embraced the programme with enthusiasm. The original plan was to establish 20 new services in 2008-09, and in fact 35 services are now up and running. The original plan was to train 700 new therapists in the first year, and in fact, over 800 trainees have joined the new workforce. Later this year, another 81 PCTs will establish services with around 1,700 more trainees. On 8 March, my right honourable friend the Health Secretary announced an additional £13 million for 2009-10 to speed up the availability of psychological therapies for people with mental health problems due to the economic downturn. This extra funding will be used largely to enable employment and psychological therapies services to work closely together to meet the specific needs of individuals who have lost their jobs or are at risk of doing so in these difficult times.
I will now refer to particular points raised by noble Lords and I apologise if I am not able to cover everything, particularly the very long list of questions asked by the noble Baroness, Lady Verma. I was not able to note them all down or find all the answers in my brief, but I promise that I will write to her to answer all her questions.
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The review of the independent Child and Adolescent Mental Health Services was raised by my noble friend Lord Layard and other noble Lords. The review was commissioned by Ministers and reported in November 2008. It identified the need to reduce waiting times from referral to treatment. The Government have accepted this recommendation in principle and have already commissioned good practice guidance in this area. Taking work in this area forward will be a priority for the national support programme. It is indeed a priority for us and the proposals of my noble friend Lord Layard are being considered as part of this programme. I believe that he is also a member of that steering group.
The noble Baroness, Lady Meacher, raised the issue of PCTs being encouraged to provide CBT. The Government have already made that clear. We have encouraged PCTs to make CBT available where clinicians prescribe it for patients. We will continue to do so. I have already mentioned that CBT should be presented to patients as a treatment option only by trained therapies as part of an overall treatment package. It is worth noting—there was some discussion about this—that this is a process that empowers patients to make choices about the treatments that are right for them.
My noble friend Lord Rea asked a series of questions about IAPT services being available for people with serious health problems. The service provides treatment for people with common mental health problems from mild to moderate depression. But people with comorbid depression, other anxiety disorders and more severe and enduring mental health problems would be able to access IAPT services for their depression and anxiety disorders. Indeed, people with drug or alcohol problems would not be excluded from receiving evidence-based psychological therapies for their depression. Where PCTs—Liverpool, for example—have identified particular local needs for people with comorbid problems, they have targeted the new IAPT services on that population. The Government are providing significant funding for people with depression and anxiety disorders for access to those therapies.
My noble friend Lord Rea also raised the issue of investment. The noble Lord, Lord Carlile, spoke of
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the importance of the range of treatments and support that should be available. My noble friend is right that we should be looking for a whole range of therapies. As CBT has the strongest evidence base for a full range of common mental health problems and there is a great shortage of fully trained therapists, we are addressing that shortage first. However, we are extending the programme to other NICE-compliant treatments for those problems. My noble friend was right to point out that other therapy disciplines do not have CBT’s level of evidence. There is quite a lot of discussion about how to deal with other therapy disciplines.
The noble Countess, Lady Mar, made a very interesting and well informed speech about CFS/ME, whose sufferers she has championed for many years. I will be pleased to investigate the issues that she has raised about CFS/ME treatment, recommended by NICE. It is important to restate the value which the Government place on the independence of NICE’s evaluation process, but I undertake to follow up the disturbing point she made and see whether I can provide her with clarification.
The noble Lord, Lord Carlile, spoke with great wisdom about the different applications of CBT in many different settings, particularly for young people. I absolutely agree with him about the need for making CBT more available in young offender units. He is right to point out the need to roll this out in rural areas and across the UK.
Since October 2007, we have invested significantly in improving access to psychological therapies. I have already mentioned the amount to the noble Baroness, Lady Verma. Psychological therapies are expanding across the country and making one of the most significant improvements in our mental health services that we have seen in decades. The Government’s commitment to that is beyond doubt, as their level of investment demonstrates. The NHS’s commitment is similarly convincingly shown by the pace with which it is establishing these much needed services. Once again, I thank the noble Baroness for bringing this important topic to the attention of your Lordships’ House.
House adjourned at 9.57 pm.