Mental health in high demand
Burgeoning talk-therapy program free for all in England
LONDON — England is in the midst of a unique national experiment, the world’s most ambitious effort to treat depression, anxiety and other common mental illnesses.
The rapidly growing initiative, which has gotten little publicity outside the country, offers virtually open-ended talk therapy free of charge at clinics throughout the country: in remote farming villages, industrial suburbs, isolated immigrant communities and high-end enclaves. The goal is to eventually create a system of primary care for mental health not just for England but for all of Britain.
At a time when many nations are debating largescale reforms to mental health care, researchers and policymakers are looking hard at England’s experience, sizing up both its popularity and its limitations. Mental health care systems vary widely across the Western world, but none has gone nearly so far to provide open-ended access to talk therapies backed by hard evidence. Experts say the English program is the first broad real-world test of treatments that have been studied mostly in carefully controlled lab conditions.
The demand in the first several years has been so strong it has strained the program’s resources. According to the latest figures, the program now screens nearly 1 million people a year, and the number of adults in England who have recently received some mental health treatment has jumped to 1 in 3 from 1 in 4 and is expected to continue to grow. Mental health professionals also say the program has gone a long way to shrink the stigma of psychotherapy in a nation culturally steeped in stoicism.
“You now actually hear young people say, ‘I might go and get some therapy for this,’” said Dr. Tim Kendall, clinical director for mental health for the National Health Service. “You’d never, ever hear people in this country say that out in public before.”
A recent widely shared video of three popular royals — Prince William, Prince Harry and Kate, Dutchess of Cambridge — discussing the importance of mental health care and the princes’ struggles after their mother’s death is another sign of the country’s growing openness about treatment.
The enormous amount of data collected through the program has shown the importance of a quick response after a person’s initial call and of a triage-like screening system in deciding a course of treatment. It will potentially help researchers and policymakers around the world to determine which reforms can work — and which most likely will not.
“It’s not just that they’re enhancing access to care, but that they’re being accountable for the care that’s delivered,” said Karen Cohen, chief executive of the Canadian Psychological Association, which has been advocating a similar system in Canada. “That is what makes the effort so innovative and extraordinary.”
‘I came out of the box’
Oliver is just the type of person the program’s two creators had in mind when they first proposed that the government fund it, a decade ago.
At 30, he was scrambling to manage a job and a young family — and unraveling fast.
After nights out with friends, he would wake up the next morning with a visceral sense that he had done something awful.
“I knew I’d done nothing wrong, I knew it, but I would start to think, ‘OK, I better check to make sure — that, like, I hadn’t hit somebody, or something,’” said Oliver, now 32 and a graphic designer outside London, who asked that his last name be omitted to protect his privacy. By spring 2015, after the birth of Oliver’s second child, the anxiety had so infiltrated his life that he had trouble leaving the house. “I was broken,” he said.
In 2005, David Clark, a professor of psychology at Oxford University, and economist Richard Layard, a member of the House of Lords, concluded that providing therapy to people like Oliver made economic sense.
“We made the case that, just on lost work alone, the program would pay for itself,” Layard said in an interview in his office at the London School of Economics.
Clark, in his university office, said: “If someone has a broken leg, he or she immediately gets treatment. If the person has a broken soul, they usually do not.”
The program began three years later, in 2008, with $40 million from Gordon Brown’s Labour government. It set up 35 clinics covering about one-fifth of England and trained 1,000 working therapists, social workers, graduates in psychology and others. The program has continued to expand through
three governments, both ideologically left and right leaning, with a current budget of about $500 million that is expected to double over the coming few years.
Under the old system, Oliver might have gotten a drug and, possibly, some general psychological guidance and support. But he had never sought mental health treatment before, and he most likely would have gone years before getting any talk therapy because he had no idea it was available. The area where he lives had scores of practicing therapists but no centralized system for ensuring that people got scientifically backed approaches tailored to their specific problem.
Oliver learned from his doctor about Healthy Minds, the program’s local center, and he immediately called. He got a call back the next day.
The promptness of that initial reply appears to be crucially important, data collected by the program suggest. If patients don’t hear back in the first few days, many of them can be lost for good because the courage it took to make the call can dissipate fast.
Andrew Prinsloo, 43, a graphic designer living in Feltham who had anxieties similar to Oliver’s, said he got a call back minutes after sending an email to Healthy Minds in late 2015. “I was having these terrible thoughts about what I might do and, honestly, I was very reluctant to talk to anyone because I thought they’d lock me up,” he said in an interview.
Patients also do simple, real-world experiments to see if feared consequences materialize. Gemma Szucs, 41, engaged in online sessions of cognitive behavior therapy over 14 weeks through the program in Oxford, for social anxiety so severe that she couldn’t bear boarding a bus because it meant attracting momentary stares from other passengers. She was referred to the program by her general practitioner.
One of the behavior experiments she tried was to carry on a loud, pretend conversation on her cellphone in the grocery store, saying things like, “I just got a call from David Cameron, and he wants to talk to you!” she said, referring to the then prime minister.
“I had to really build myself up to do this,” she said. “But then when I finally did it, no one batted an eyelid. Nothing. I felt ridiculous for worrying about it at all.”
Oliver’s challenge was to work his way through a list of previously routine activities that had become terrifying, like driving (lowest on the list) and jogging in a remote area of the woods (at the top).
“It was hard, but I got through it,” he said. “The therapy worked — I came out of the box I was living in.”
A mental health waiting list
The biggest challenges may be those created by runaway demand. Therapists are booked solid; some are juggling 25 clients at a time, and the line to get in the door is long, creating the same complaints about waiting lists that the National Health Service has for many medical services and procedures. The average wait is 31 days for a course of therapy, typically shorter for the online variety and longer for face-to-face treatment.
Directors of the local centers have managed this caseload with the tools they have, in part by seeing to it that wouldbe clients get educational materials or online resources right away, to give them something to study while they wait for an appointment.
Sarah Norman, 45, a pediatric nurse who sought help for depression last year from the Oxford center, said she was referred to group therapy because the waiting list for individual therapy was so long. When the group therapy ended after four sessions, she remembered: “I was a bit frustrated. I thought I could have used a couple more sessions.”
She did, in time, improve, and is very grateful for the treatment. The same cannot be said with any certainty about the 40 percent of people who the data show were lost to the program after the initial assessment phone call. About two-thirds of them were not depressed or anxious enough to qualify for the therapy, or decided it wasn’t for them, Clark’s data show.
That leaves about 125,000 men and women who may have needed help but didn’t get it. “These are people we’d like to reach, and we are pushing the services hard to do that,” Clark said.