Developments in UK mental health treatments 23 May 2023
In 2011 the UK government set out long-term goals to improve mental health services and bring them on a par with physical health services. Acknowledging a large ‘treatment gap’ for those with mental health problems, in 2016 the Department of Health and Social Care (DHSC) and NHS England committed to improving and expanding NHS-funded services. Commitments were outlined in the ‘Five Year Forward View for Mental Health’ (July 2016); ‘Stepping forward to 2020/21: The mental health workforce plan for England’ (July 2017), and ‘The NHS Long Term Plan’ (January 2019).
In 2021-22 the NHS spent around £12 billion on mental health services, or around 9% of the NHS budget. There were 4.5 million people in contact with NHS-funded mental health services during this period.
In February 2023 the National Audit Office (NAO) report ‘Progress in improving mental health services in England’ investigated the status of mental health provision and whether government expenditure had been cost effective.
Looking at talking therapy services, the report found that the number of people accessing these was below target before the pandemic, while in 2021-22, 1.2 million people accessed the service – 22% below the target of 1.6 million.
The NAO noted that, although the NHS mental health workforce had increased by 22% between 2016-17 and 2021-22, staff shortages remained the major constraint to improving and expanding services. The overdue NHS workforce plan is expected in 2023.
For the period 2023-24, the report stated that there would still be sizeable treatment gaps. It estimated that the 2023-24 ambition for 1.9 million people to access talking therapy services equated to around one quarter of people with a diagnosed need.
Clearly, with mental health staffing levels below those required, other options must be considered that could reduce the burden.
On 16 May 2023, the National Institute for Health and Care Excellence (NICE) announced that it has recommended nine digitally enabled treatment options for depression or anxiety for use in the NHS, while further data are gathered on their clinical and cost effectiveness.
The therapies have been recommended under its early value assessment (EVA) pathway, which was established to fast-track promising health technologies with potential to address national unmet need.
Six of the treatments are for adults with anxiety disorders and three are for those with depression.
They offer cognitive behavioural therapy (CBT) methods via an app or website, with support from an NHS Talking Therapies clinician or psychological wellbeing practitioner.
Digitally enabled therapies for depression require on average 90 minutes with a therapist. This compares with the eight hours each patient would receive with standard care, according to NICE.
Digitally enabled therapies for anxiety require an average of four hours of clinician or practitioner time, compared with 10 hours required for standard care.
A benefit of the digitally enabled therapies is that they give the user more flexibility to choose the time and location of their treatment. Their use should also free up therapists’ time so they can focus on increasing access elsewhere in the health system or reduce waiting times.
However, Marjorie Wallace, founder of the mental health charity SANE, noted that digital therapy “may be very useful for some” but was “no substitute for a one-to-one relationship with someone who knows their story”.
“Our experience with those who contact us is that self-diagnosis and techniques of self-management do not always reach the layers of their inner mental pain and can leave them feeling even more unsafe and alone,” she commented.
NICE states that digitally enabled therapies may not suit everyone and some people may prefer another option, such as face-to-face therapy. In addition, digitally enabled therapies may not be suitable for those with limited access to equipment or an internet connection, or who are less comfortable or skilled at using such technologies.
A formal assessment with an NHS Talking Therapies clinician or practitioner is required prior to a patient starting treatment to ensure the correct intervention is matched to both clinical needs and the person’s preferences.
In 2021-22, there were 527,094 referrals accessing NHS Talking Therapies for depression and anxiety with a presenting complaint of anxiety and stress-related disorders.
Some of the digitally enabled therapies are already in use. The nine digitally enabled therapies recommended by NICE will require Digital Technology Assessment Criteria (DTAC) approval, a completed NHS Talking Therapies for anxiety and depression digitally enabled therapies assessment from NHS England, and a CE or UKCA mark approval before they can be used by the NHS while further evidence is generated.
Further evidence will be generated over the next three years to establish whether the therapies deliver in practice.
The three for treating depression are Beating the Blues, Deprexis and Space from Depression.
Those for anxiety disorders are Beating the Blues and Space from Anxiety (for generalised anxiety symptoms or unspecified anxiety disorder), plus iCT‑PTSD for post-traumatic stress disorder (PTSD), iCT‑SAD for social anxiety disorder, Perspectives for body dysmorphic disorder and Spring for PTSD.
The therapies will be assessed for a range of criteria, including rates of recovery, rates of improvement, deterioration, relapse, patient experience and adverse effects.
Demand for mental health services is likely to be higher than the 2019 NHS Long Term Plan anticipated, considering the effects of the pandemic and the steep increase in numbers of young people presenting with mental disorders. While digitally enabled therapies may not suit everyone, if proven effective, the hope is that they could help some patient populations and release staff hours to focus on in-person services.