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Whose Choice? The changing face of mental health services

by Nicky Lidbetter, Big Life Director of Mental Health.

Those of us that have been knocking around the mental health world for as long as I have (25 years +) will know that treatments for various emotional and wellbeing issues seem to go in and out of fashion. Some stay in favour for long periods of time while others are short lived fads. Remember the wristband era, when sporting a band promoting various causes became hugely ‘on trend’? Wearing a wristband made a statement about what you believed in or experienced and was a mark of solidarity. In those days, the only talking that was being done about mental health was either prompted by spotting someone’s wristband or following a tabloid headline about ‘psychotic murderers’.

Thankfully times have moved on. We’ve gone from a time when a personal disclosure of anxiety would generate surprise and curiosity, to a new era where everyone seems to have their own story to share. Pretty much every celebrity has had a form of anxiety or depression and, arguably to be ‘credible’ with their audience, this is almost essential.

So, if common mental health problems are becoming more talked about and more ‘common’ – it stands to reason that the treatment landscape has similarly ‘moved on’ – or has it?

When I first entered the world of mental health, pharmaceuticals and psychiatry really dominated. Going to a GP feeling depressed or unable to cope often had one outcome – a prescription. It was the era of Selective Serotonin Reuptake Inhibitors or SSRIs as they are commonly known – a time when all things mental health was said to be fixed by medication. We were told that depression and anxiety, and other serious mental illnesses, could entirely be accounted for by chemical imbalances in the brain, which could be rectified by antidepressants that were so clever that they targeted the 5-hydroxytrptophan pathway (5-HT).  As a former neuroscientist that had held a position in the anxiolytics department at an international pharmaceutical company, this made sense to me. SSRIs were the silver bullet, or so we were told. These newer drugs were much more target specific and not as ‘dirty’ as previous compounds routinely prescribed for common mental health difficulties. While the SSRIs were better than we’d ever had before, they were not without their difficulties – including side effects such as sexual dysfunction and nausea. Discontinuation syndrome was also a known problem with some of the SSRIs. Consequently, pharma companies had large psychiatric divisions – all on a quest to find the next antidepressant or anxiolytic.

In a very short space of time, the UK saw the number of prescriptions for SSRIs and SSRI-like medication go through the roof. Everyone it seemed was depressed and the country’s mental health could be sorted through medication. While the so-called ‘worried well’ (those with anxiety and depression) were not featuring in the headlines of newspapers, those with serious mental illnesses were, and the policy of containment continued.  Right until the mid-2000s, pharmacology was ‘big’ in the world of mental health. For most, it was the only treatment offered.

By now you might think that I am anti-psychiatry and anti-medication…. I am not. I just feel that to attribute the cause of all mental ill-health to various forms of neurotransmitter imbalance is naïve and overly simplistic. There is wide acceptance now that mental health is affected by social as well as physical and environmental factors and that drug treatment cannot be the only response. I am personally passionate about ensuring that people are given access to a range of treatment options. Choice is important in mental health because it is a hugely subjective area. While people might share some common symptoms, I have yet to find two people who have exactly the same manifestation of depression or anxiety.

If someone said to me, ‘you can only shop at Tesco’, I would be frustrated;  wanting to see what other stores might have to offer. It’s the same with mental health services:-  I don’t want to be told there is only one treatment – I want to shop around, consider all the options and then decide what is best for me.

That’s why in 1995, I set up the first self-help group for people experiencing anxiety in Manchester. Peer support and self-help has played a key role in mine and other peoples’ lives for years but has never formed a central role in mental health treatment. Traditionally it has been the domain of community and voluntary organisations who have scraped together bits of funding to provide these services and which have always been on the periphery and certainly not considered an integral part of the mainstream offer.

The preference for medication as a treatment for anxiety and depression continued until the early 2000s. It was acknowledged that people with anxiety and depression accounted for the biggest chunk of overall mental health prevalence and that the antidepressant bill was only going to rise. The answer was… the Improving Access to Psychological Therapies Programme (IAPT).

IAPT is probably one of the single largest mental health initiatives that the NHS has ever launched. Developed directly as a result of the National Institute for Health and Care Excellence (NICE) recommendation that talking therapies be a key treatment in the management of anxiety and depression – IAPT was launched to enhance the NHS talking therapy offer.  IAPT provided a new workforce of Psychological Wellbeing Practitioners (PWPs), able to offer Cognitive Behavioural Therapy (CBT) to large numbers of people at relatively low cost; placing talking therapies firmly on the primary mental health care landscape for the first time.

People say that the IAPT initiative came about as a direct result of economics and was all about tackling the rising number of people in receipt of welfare benefits as a result of having a mental health problem. This in part might be true, however the increasing number of prescriptions for SSRIs and headlines such as ‘Prozac nation’ also fed into the national psyche, prompting those in positions of power to question whether we really wanted to see the answer to addressing common mental health and wellbeing issues as being medication.  Of course, increased prescriptions also meant a rising medication bill which, coupled with the start of the economic downturn, meant for an increased focus on finance and cost cutting.

Prior to IAPT, it’s fair to say that the NHS psychological therapy offer for common mental health difficulties was a real mixed bag. It was not uncommon for people to sit on lengthy waiting lists of over a year, if not longer, with relatively simple presentations of depression and anxiety being seen by highly qualified psychological therapy professionals – often psychologists. Throughout the 90s and early 2000s, we’d all become accustomed to the person-centred counselling approach and recognised the complementary role such services played in the provision of mental health services. And so, with the arrival of CBT, the new kid on the block, many found that person-centred counselling was quickly falling out of favour. Those counselling services that did manage to survive around the advent of CBT and IAPT, had to quickly ’IAPT-ise’ and get on board with the new recovery measures and data collection requirements made of IAPT services.

Critically, CBT became firmly and squarely positioned in pole position in comparison to other talking therapies. Fidelity to the IAPT model became very important and the concept of brief therapy was introduced. No longer was it expected that clients would languish on long waiting lists, but instead would be provided with a step 2, low intensity service, which many equate to ‘light touch’ therapy. Interestingly, though there continued to be little or no NHS investment in self-help or peer support services, IAPT was initially seen as a service that would train and employ people with lived experience of mental health issues; such individuals it was envisaged would make up the main bulk of the step 2 IAPT workforce. In our own Self Help Services, we have always been proud that over 60% of our IAPT staff are individuals with lived experience of mental health difficulties. However, this has not been the predominant profile of staff employed in IAPT services in NHS Trusts.

Along with IAPT, we were introduced to the Stepped Care Model (Scogin, 2003), which brought a new language to mental health services, where the ‘least intensive intervention is offered at the earliest point in time’. Terminology such as ‘stepping up and down’ became routinely embedded into the primary mental health care landscape. The concept of ‘time-limited therapy’ was introduced, so no longer were clients facing long waits for therapy but instead were being increasingly provided with quick access to a ‘brief therapy’ intervention.

As the years ticked by, we started to see a new dominant force emerge; that of evidence based psychological therapies and with this, medication seemed to be on the back burner. Although medicines management forms part of the overall biopsychosocial assessment that low intensity IAPT PWPs undertake, prescribing is not. Some Psychopharmacologists continued to highlight the need for combination therapy i.e. a psychological intervention combined with psychiatric medication, but by and large this voice became a faint one. In fact, I would be willing to place a bet that few individuals practicing in the field of primary mental health care today would be able to readily cite what combinations of talking therapy and psychiatric medication make for the best treatment outcome in various forms of anxiety and depression.

Just though as I’m not anti-psychiatry, nor am I anti-IAPT. In fact, I firmly believe that IAPT has done more for anxiety and depression than any other single programme has. It has succeeded in putting common mental health disorders on the map and has ensured that the thousands of people affected by depression and anxiety receive timely and accessible help.

We now also have many thousands of CBT-trained workers, which makes for quite a formidable force for change. However (returning to my supermarket analogy), just as with anything in life; too much of a good thing can end up in you going off it. I say this as I’m wondering if we are slowly starting to go off CBT? Is it the case that CBT has replaced pharmacotherapy as the ‘only shop in town’ and in doing so, has been overly positioned as the answer to everything when in fact it has its limitations – just like any intervention does?

I mentioned that I’d been in this world of mental health for some time and that over the years I have seen a lot of things, including what I might term as the ‘reacceptance of other forms of psychological therapies’ such as person-centred counselling. Yes, counselling as we knew it in the pre-mid 2000s it seems is starting to be recognised for the value it can bring to the primary mental health treatment landscape. Indeed, looking to the future, we can see some signs of change…. For example, there are emerging discussions about expanding the range of talking therapies on offer to include so-called third wave CBT approaches with modalities such as Compassion Focussed Therapy (CFT) coming to the fore (an approach which helps people develop self-soothing and self-compassion skills).  Even the categorisation of mental health problems is changing with clinicians increasingly choosing transdiagnostic approaches as opposed to disorder-specific ones. Other interventions and approaches, such as peer support and self-help initiatives, are too starting to gain traction. In 2019, the NHS launched a programme of investment in Peer Support Workers; roles which are now being created up and down the country in mental health trusts and which are being seen as a critical component of the future mental health workforce.

Self-help and peer support however is something that we have been doing for well over 25 years.   In fact these support services are the bedrock of everything we do. Our self-help groups continue to operate on a weekly basis, forming a lifeline for those in the communit, while keeping many from needing more intensive and costly NHS services. Our peer support, guided e-therapy, online Learn Well training, and self-help groups have enabled thousands of people to develop tools to help themselves and connect with other people that are going through similar experiences; facilitating friendships and breaking isolation. We have tried to embed these services alongside IAPT and counselling services in order to offer a choice to people at a time when they are looking for help, but NHS investment in these services remains marginal and they are seen as the ‘nice to haves’ rather than being part of the essential offer available at primary care level, though this looks set to change. Indeed, we do seem to be slowly moving towards an acceptance that not all approaches suit everyone and that a ‘mixed bag’ approach might actually be better. So, you can buy more than one product and critically, you can shop at a range of shops and….. it might just be that different approaches complement one another.

Of course, the bigger movement that is going on here is a much welcomed shift away from the medical model to that of a social model of mental health; something that I honestly did not think that I would ever see in my lifetime, but which is just so heartening to witness.   Lived experience is now valued and is working its way to being on a par, skill set wise, to that of clinical training. Critically we are seeing a recognition that a person’s experience of mental health difficulties not only gives them such a unique perspective, but that it can provide that ‘magical ingredient’ in a service interaction that just makes all the difference. It is recognised that people with lived experience should no longer be confined and pigeon-holed into service user or peer support roles, but increasingly should be encouraged by the trusts and organisations that employ them, to take up clinical and management roles (if they should so wish). We are seeing increasing numbers of mental health professionals that successfully combine lived experience with clinical training – again something that would not have been seen when I first began working in mental health. In fact, I can recall many a time when I would have to decide what ‘camp’ I was in when at external events – was I a service user because of my lived experience of anxiety, or was I a mental health professional because I was a clinician and a senior manager of a mental health organisation? At the time, unbelievably, it was not possible to be both.

The world is changing though and mental health services are not immune from being affected by digitalisation. There are a lot of exciting opportunities coming up to really transform how we help and support people with mental health difficulties. Tech in mental health is probably one of the fastest growing areas of digitalisation. We now have so many products and services chomping at the bit to get in the mental health shopping basket that it will not be long before we have a really robust and expansive menu from which to choose. Virtual Reality (VR) therapy for example, has great potential in the treatment of many mental health issues.  Artificial Intelligence (AI) too has the potential to disrupt existing pathways and could lead to the introduction of AI therapists in the future, thus significantly impacting on how services are delivered and who delivers them.

The NICE guidelines for the treatment of generalised anxiety disorder with panic disorder also are due to be refreshed any time now. It will be interesting to see what is recommended in this document, once produced. I feel certain that we will see a diverse portfolio of products and services in the treatment of anxiety and depression, which feels right.

Cannabinoid substances might soon become a direct competitor to current mental health treatment approaches, as research in this area is fast moving and this combined with a huge market for self-management and online consumerism makes for what is likely to be a transformative mental health landscape.

One thing is for certain however; things do often go full circle. What fell out of fashion will at some point come back into fashion – though perhaps never in exactly the same form, just like real fashion. Choice is important in mental health because it is a hugely subjective area of health. While people might share some common symptoms, I have yet to find two people who have exactly the same experience of depression and anxiety, and so it is important that we get better at offering different services and that we don’t become overly wedded to any one single approach. Putting one’s eggs in one basket is a recipe for disaster and so we must always keep an eye out for what is coming next. As a nationally recognised provider of mental health services, maintaining our reputation for innovation and excellence and, importantly, doing what we feel is right when it comes to supporting people who are experiencing anxiety and depression, remains as pivotal now as it always has been.