Why Do Fewer Than One in Three People With Mental Illness Receive Treatment?

While most people with physical illness are in treatment, this is true for fewer than one in three people with mental illness... What could account for this shocking failure? Stigma is one reason. People are ashamed of being mentally ill.

This is the second part of a series of extracts from Richard Layard and David M. Clark'sThrive: The Power of Evidence-Based Psychological Therapies. The first part can be read here

It is not surprising that most mental illness goes untreated. While most people with physical illness are in treatment, this is true for fewer than one in three people with mental illness. This figure applies throughout the advanced world, and even for major depressions the figure is under a half in Britain, the USA, and continental Europe. If your pancreas is not working you automatically get treatment, but if your mind has been disordered for decades you do not.

What could account for this shocking failure? Stigma is one reason. People are ashamed of being mentally ill. They feel that, while physical illness is an act of the gods, mental illness is in some way their own fault. Relatives are also full of guilt. So in most countries no effective lobby exists on behalf of people with mental illness, as it does for heart disease, cancer and the like.

But another important reason is simply technological lag. Many people don't know that we have new treatments for mental illness that are just as effective as the treatments for many physical illnesses.

Can they be treated effectively?

This is a new situation. Until the 1950s there were no scientifically validated treatments for mental illness. But in that decade there were major discoveries of drugs that could help to control psychotic symptoms (the anti-psychotics) and depression (the anti-depressants). Even so, many sufferers are averse to drugs, often because of their side effects, and that partly explains the low numbers in treatment. But then in the 1960s and 1970s came major breakthroughs in psychological therapy. The most important of these was what is now called Cognitive Behavioural Therapy (CBT), which relies on the fact that thoughts affect feelings, and that good mental habits can be systematically built up step by step. CBT is certainly not the only therapy which works, and it does not always work. But it has been evaluated so much more often than any other therapy that we can speak with certainty about its average overall effects. These have now been established in hundreds of randomised clinical trials of exactly the same kind as are used in testing any medical treatment.

The general finding is that around 50% of people treated with CBT for depression or anxiety conditions recover during treatment, and many others improve significantly. For depression, CBT is as effective as drugs in the short run, and more effective in preventing the recurrence of depression down the road. For anxiety, CBT is even more impressive. Many people with conditions like social phobia, panic disorder or obsessive- compulsive disorder have had their condition for decades, but if successfully treated they are mostly cured for life.

A leading hero of this 'psychological revolution' is the psychiatrist Aaron Beck. He began as a psychoanalyst, and wanted to make psychoanalysis scientific. So he designed a study to confirm one of its central tenets - that depression is due to unconscious hostility that has been repressed and directed against yourself. With a team of colleagues, he compared the dreams of depressed and non-depressed patients. Contrary to his expectations, it turned out that the depressed patients had less hostility in their dreams than the other patients did. However, their dreams did seem to be quite similar to how they were actually thinking when awake. They saw themselves as victims; people or circumstances were against them; they felt thwarted, rejected or deserted.

So Beck focused all his efforts on what his patients were actually thinking - getting them to observe the automatic thoughts which were part of their thinking style. He sat facing them to try and detect their unspoken thoughts. When a cloud passed over a face, he would say, 'What was going through your mind just then?' It turned out that the thinking style of depressed people included catastrophising (thinking the worst), black-and-white judgements, and overgeneralising from a single bad experience. To help his patients, Beck trained them to examine their thoughts and how they might be biased or distorted. To his surprise, they often stopped coming to see him within twelve sessions, saying they had had all that they needed.

Another hero of the 'psychological revolution' was Joseph Wolpe, a South African psychologist. He also trained in psychoanalysis but was frustrated at the slow pace of treatment. He read the work of the Russian physiologist Ivan Pavlov, which showed that fears in animals could be extinguished by exposing the animal to the object of its fears in a gradual way. Wolpe applied this form of behaviour therapy to his clients and, like Beck, found they recovered quickly. Beck and Wolpe had essential insights that became combined in the development of cognitive behavioural therapies. To ensure that their new treatments could have reliable results, they developed manuals of good practice which any well-trained practitioner with enough empathy could apply. And, to measure effectiveness, they developed rigorous scales of measurement and used these in scientific randomised trials to find out what proportion of patients recovered. The resulting recovery rates of 50% or more now offer hope to millions of people worldwide.

There are certainly other therapies which can also be extremely effective. They need to be systematically developed and tested. So when the history is written we shall hopefully see how CBT paved the way for other, perhaps more powerful, therapies. But for the moment, what CBT has done is to bring psychological therapy to a point where it can claim scientifically to be able to transform lives. It will be seen to have changed our culture forever.

One striking fact about modern treatments (be they drugs or therapy) is the rigour with which outcomes are measured. This is far from the vague, less structured and more prolonged therapy which many doctors tend to despise. It is science of a high order, based on randomised controlled trials and capable of replication, with success rates as high as in the majority of treatments available for physical illnesses. But not enough people know this, and evidence-based psychological therapy is hard to access in almost every country.

Thrive: The Power of Evidence-Based Psychological Therapies, by Richard Layard and David M Clark, is published by Allen Lane on 3rd July 2014, priced: £20. Available from Amazon

Richard Layard is one of the world's leading labour economists, and in 2008 received the International Prize for Labour Economics. A member of the House of Lords, he has done much to raise the public profile of mental health. His 2005 book Happiness has been translated into 20 languages.

David M Clark, Professor of Psychology at Oxford, is one of the world's leading experts on CBT, responsible for much progress in treatment methods. With Richard Layard, he was the main driver behind the UK's Improving Access to Psychological Therapies programme.