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Is the Future Digital for Psychological Therapies?

11/04/2016 17:20 | Updated 11 April 2016

You may have noticed that mental health has been firmly on the media agenda of late. There's a reason for that: in recent weeks the Mental Health Taskforce recommended that NHS England increase the access targets for the 'Improving Access to Psychological Therapies' (IAPT) programme from 15 per cent to 25 per cent.

This recommendation was accepted by NHS England and endorsed in the budget. If the target is met it will mean 600,000 more adults with common mental health issues such as anxiety and depression being able to access therapy.

The IAPT programme first began life in 2006 helping to make psychological therapies an alternative to GPs simply relying on the prescription of drugs. Given that just in the last few weeks, the World Health organisation (WHO) expressed concern about the news that between 2005 and 2012 there was a 54% increase in the number of young people prescribed antidepressants in the UK, there is clearly still some way to go. That said, a recent survey suggests that GPs' reliance on medication is lower in England than Scotland and Wales, where no equivalent of the IAPT programme exists.

Increasing access to therapy presents a number of challenges for local mental health services, such as finding enough trained staff to deliver the service, getting people into the service and achieving good results. Currently, waiting times, a lack of trained staff and even a lack of willingness among patients - particularly those from a black or minority ethnic (BME) background - to access these therapies all present obstacles. Healthcare commissioners and providers will have to think imaginatively in order to meet this new target with the resources available.

As the taskforce report observes: "Leaders across the system must take decisive steps to break down barriers in the way services are provided to reshape how care is delivered, increase access to the right care at the right time, drive down variations in the quality of care on offer, and improve outcomes."

The delivery of conventional CBT is quite rigid, with appointments usually taking place face to face, and there are significant waiting times for them. People who work can find it difficult to fit appointments around their daily lives. Similarly, new mothers facing postnatal depression, a group prioritised by the Task Force, are sometimes less able to leave home and attend sessions with a young baby.

Another drawback of face to face CBT is that there is no written record of the therapy sessions. In order for CBT to be effective the therapists delivering the service must adhere to evidence based treatment protocols, but without written records, it is impossible to monitor how these standards are being delivered without an invigilator.

Digital access to psychological therapy provides a solution to many of these problems but it needs to be distinguished from the multitude of self-help apps, many of which have no evidence to support them. In particular, it is not based on algorithms or interaction with peer groups but led by a qualified therapist.

CBT delivered online via typed messaging offers some key advantages: it can be flexible - there is the opportunity to fit the sessions around a busy working life. This is advantageous both for the patient and the trained therapist at the other end. But there is also an empirical upshot: digital CBT sessions provide a wealth of data in the form of written transcripts, which can be used by the therapist and provider to improve performance and as a source of reference by patients to sustain outcomes.

Examination of the work of over 200 CBT therapists working online using written communication demonstrates that those therapists that get the best results are the ones adhering to evidence-based treatment plans. It has never been possible to demonstrate this before with certainty.

There is also the advantage for the patient in having a written record of the sessions. CBT does what it says on the tin: it helps you change the way you think and the way you behave. But you need to keep practising it, and having all the tips and strategies you learn during the course of treatment written down provides a valuable source of reference for patients, supporting their sustained recovery. You can look back at your notes and keep on track.

Digital access to CBT fits in well with the NHS's Five Year Forward View, which stresses the importance of a "proactive and preventative approach" to mental health. The clinical outcomes achieved are fully comparable with face-to-face therapy but with the enhanced efficiency that a digital platform enables - an important consideration for busy people in hard-pressed times.

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