Improving Access to Psychological Therapies (IAPT) has potential but is not sufficient: How can it better meet the range of primary care mental health needs?

Abstract

BackgroundThe Improving Access to Psychological Therapies (IAPT) programme has been impactful in increasing access to psychological therapies at primary care level. However, it remains unclear whether IAPT’s widely disseminated achievements include the reduction in service users’ transition to secondary care services and whether IAPT services are providing interventions that match the level of complexity of presenting problems of those who are referred.AimsThis review sets out to clarify the clinical characteristics of IAPT cohorts, whether the interventions provided target these characteristics, and whether outcomes are related to the use of the stepped‐care model advocated in the operationalization of IAPT services.MethodA systematic literature search was undertaken on PsycINFO, MEDLINE, and Embase using the terms: IAPT, anxiety, and depression.ResultsOf 472 paper identified, 24 articles were deemed pertinent. It appears that IAPT cohorts are complex and current service delivery frameworks may not meet their needs. IAPT developments and research for long‐term physical health conditions and serious mental illness have been recently advocated, though whether these are sufficient and viable when set in IAPT’s prescriptive backdrop remains unclear.ConclusionsImproving Access to Psychological Therapies provision and research at present does not adequately consider the complexity of its clientele in the context of treatment outcomes and service delivery. Recommendations are provided for future research and practice to tackle these deficiencies.Practitioner Points Improving Access to Psychological Therapies (IAPT) has significantly increased access to psychological therapies within primary care over the last decade, though it is unclear whether its interventions are sufficiently tailored to meet the actual levels of complexity of its clientele and prevent them from needing onward referral to secondary care as originally envisaged. Given the ongoing focus on and investment in IAPT informed developments into long‐term conditions and serious mental illness, this review considers whether additional elucidation of the model’s original objectives is required, as a precursor to its expansion into other clinical areas. The review indicates that there is a stark lack of data pertaining to the generalisable, real‐world clinical benefits of the IAPT programme as it currently stands. Recommendations are provided for future areas of research, and practice enhancements to ensure the value of IAPT services to clients in the wider context of NHS mental health services, including the interface with secondary care, are considered.

Personalised psychotherapy in primary care: evaluation of data-driven treatment allocation to cognitive–behavioural therapy versus counselling for depression

“… 35 In addition, whereas all treatments in IAPT are delivered by mental health professionals, who are trained in accordance with the national curriculum, there are currently no measures of treatment fidelity in IAPT, making judgements about the adherence to treatment protocols difficult. 36 As such, the present study serves as an explanatory exploration, with more rigorous and causal research required prior to application in practice, such as evaluations in a randomised controlled trial.…”

Trajectories of depression and generalised anxiety symptoms over the course of cognitive behaviour therapy in primary care: an observational, retrospective cohort

“…Disentangling the complex nature of psychotherapies and how these relate to specific symptoms would have important implications for precision psychiatry – a more detailed understanding of which therapeutic techniques have an effect on specific symptoms could potentially lead to better treatment matching on both empirical and theoretical grounds. However, having no detailed information regarding the order/nature of specific techniques and the lack of fidelity measures in IAPT make this difficult to assess (Martin, Iqbal, Airey, & Marks, 2022). Component studies of CBT, which also look at symptoms rather than sum scores alone, may be beneficial in gaining more granular insights into CBT; however, to date, efforts to understand specific therapeutic techniques appear underpowered (Cuijpers, Cristea, Karyotaki, Reijnders, & Hollon, 2019).…”

“…While efforts were made to capture a sample of patients who received high-intensity CBT, there are limitations of examining treatment in observational data. While clinicians are trained in accordance with clinical protocols, the lack of treatment fidelity measures in IAPT (Martin et al, 2022) raises possible concerns about the consistency and fidelity to protocol of treatment that are delivered in routine care. A lack fidelity is likely to dilute any observed effects.…”

Psychiatric diagnosis and treatment in the 21st century: paradigm shifts versus incremental integration

“…Such a trial has not been conducted and probably never will be. Thus, although it is possible to claim on the basis of outcome data from routine care that other services are as effective as IAPT 146 , or that IAPT services may not pro vide interventions that match the level of complexity of the problems of patients 147 , it is difficult to validate such claims.…”