Is the problem with mental health provision accessibility or effectiveness?

Last week, we saw some interesting proposals from the Secretary of State for Work and Pensions linked to the rise in Personal Independence Payment (PIP) claimants for mental health.??

The numbers are very concerning. In 2019, there were an average of just under 2,200 new PIP awards a month where the main disabling condition was mixed anxiety and depressive disorders. This has more than doubled to 5,300 a month in 2023. This illuminates a well-established trend in England’s health, particularly since the pandemic: our mental health is deteriorating.??

Like so many other parts of the primary care system, demand significantly outstrips capacity in mental health provision. The policy issue is therefore often diagnosed to be accessibility, rather than effectiveness. But poor accessibility can often mean there is relatively little scrutiny of the efficacy of the interventions on offer. By the time someone actually receives care, they’re so relieved to receive it there’s not much room to scrutinise the available options.??

But the effectiveness of the interventions, not just the availability of them, is crucial to reducing the ever growing mental health problem in England. So let’s scrutinise the evidence available. There are broadly two approaches a GP can take with mental health disorders: medication and talking therapies.??

The increase in prescriptions far outweighs the increase in referrals for talking therapy. In 2021-22, 8.3 million received antidepressant prescriptions, while 1.8 million were referred to talking therapies —? four times as many individuals being offered access to pharmaceutical care than psychological care.?

The effectiveness of antidepressants is generally good and continues to get better. The most commonly prescribed antidepressants are selective serotonin reuptake inhibitors (SSRIs) which were developed in the 1970s. These drugs are predicated on the idea of a ‘chemical imbalance’ in the brain — mostly serotonin — an idea which is widely subscribed to among professionals and the public alike as the cause for mental health disorders .?

However, like many drugs, SSRIs are effective but not perfect. They are known for their unpleasant side effects — weight gain, effects on sleep (anything from insomnia to vivid dreams), and sexual dysfunction. And while they do work for many people, antidepressants work very differently for different patients and can be unpredictable. ?

Determining the right trade off of side effects versus improvement in mood can be a gruelling process. Antidepressants often involve headache, nausea and dizziness when first prescribed, with no guarantee that an antidepressant will work and forcing the patient to endure another six weeks of experimentation with another antidepressant. They can also lead to a lifelong dependence on these drugs.??

It's worth noting an academic debate has emerged in recent years challenging the idea that a serotonin imbalance in the brain causes depression , perhaps suggesting there could be other, more effective solutions out there yet to be unearthed.??

Popular culture will have many believing talking therapy involves a chaise longue and an inscrutable therapist. The reality in the public sector is very different. Therapy is highly structured and often done in groups. The NHS technically offers several different types of therapy , but by far the most common type of therapy used is cognitive behavioural therapy (CBT), swiftly followed by ‘guided self help book’ and counselling for depression.??

CBT is more akin to a lesson than a therapy session. It teaches a patient why their brain is making them think the way they do, and how to break the cycle of negative thoughts. It is very skills focused, which is why it is often delivered in groups and online rather than a one to one session. It explicitly does not address wider problems in a person’s life that may have a significant impact on someone’s health and wellbeing. This may partially explain the dissonance between the clinical evidence and the patient experience : clinical evidence suggests CBT is effective for targeting moderate anxiety, but only 39 per cent of recipients of talking therapy found that it worked .??

There are many questions that arise from the evidence surrounding efficacy of mental health interventions. Could more be done to support clinical research into SSRIs? Is the poor patient experience of therapy mostly due to the fact we don’t have enough therapists, which therefore restricts the NHS’s counselling offer? Or is it that actually the offer from NHS talking therapies needs to be fundamentally different? And lastly, how could private sector capacity be leveraged to deliver more talking therapies in the public sector???

The mental health burden in England only continues to grow —?at an alarming rate — with a hefty cost for the tax payer, as the DWP green paper demonstrates. These questions will need answers. ?