Cost of Improving Access to Psychological Therapies (IAPT) programme: An analysis of cost of session, treatment and recovery in selected Primary Care Trusts in the East of England region

https://doi.org/10.1016/j.brat.2012.10.001Get rights and content

Abstract

Recent literature on Improving Access to Psychological Therapies (IAPT) has reported on improvements in clinical outcomes, changes in employment status and the concept of recovery attributable to IAPT treatment, but not on the costs of the programme. This article reports the costs associated with a single session, completed course of treatment and recovery for four treatment courses (i.e., remaining in low or high intensity treatment, stepping up or down) in IAPT services in 5 East of England region Primary Care Trusts. Costs were estimated using treatment activity data and gross financial information, along with assumptions about how these financial data could be broken down. The estimated average cost of a high intensity session was £177 and the average cost for a low intensity session was £99. The average cost of treatment was £493 (low intensity), £1416 (high intensity), £699 (stepped down), £1514 (stepped up) and £877 (All). The cost per recovered patient was £1043 (low intensity), £2895 (high intensity), £1653 (stepped down), £2914 (stepped up) and £1766 (All). Sensitivity analysis revealed that the costs are sensitive to cost ratio assumptions, indicating that inaccurate ratios are likely to influence overall estimates. Results indicate the cost per session exceeds previously reported estimates, but cost of treatment is only marginally higher. The current cost estimates are supportive of the originally proposed IAPT model on cost-benefit grounds. The study also provides a framework to estimate costs using financial data, especially when programmes have block contract arrangements. Replication and additional analyses along with evidence-based discussion regarding alternative, cost-effective methods of intervention is recommended.

Highlights

► Cost of single session, completed course of treatment and recovery in IAPT were estimated. ► Average high intensity session cost £177 and low intensity session cost £99. ► Average cost of treatment was £877 for all treatment types. ► Cost of recovery per patient was £1766 for all treatment types. ► Current cost estimates are supportive of the original IAPT model on cost-benefit grounds.

Introduction

Large, multinational epidemiological studies indicate that approximately 16% of the population experience depression and anxiety over a lifetime (Kessler et al., 2003; Singleton, Bumpstead, O'Brien, Lee, & Meltzer, 2001). In UK, a 2006 report from Centre for Economic Performance (CEP) stated that “crippling depression and chronic anxiety are the biggest causes of misery in Britain today” (CEP, 2006). The financial cost of depression in the UK was estimated at approximately 105 billion pounds in 2009/2010, of which 30 billion is thought to be work related (Sainsbury Centre, 2010). Furthermore, it has been estimated that a cross subsidy of £7–10 billion on social security benefits payments are made to cover the unemployment costs of people with high prevalence mental health problems (CEP, 2006).

To alleviate the distress and costs associated with depression and anxiety disorders, the UK Department of Health announced an unprecedented increase in funding for the provision of psychological therapies in the National Health Services in 2007 (DoH, 2007). With the possible exception of the closure of asylums and the associated increase in community based mental health treatment in the 1960s, the Improving Access to Psychological Therapies (IAPT) programme represents the biggest shift in policy in UK mental health service provision in the past 50 years. Based on economic arguments and clinical evidence, IAPT was developed to promote access to National Institute for Health and Clinical Excellence (NICE) approved Cognitive Behavioural Therapy (CBT) based talking therapies as an appropriate evidence-based psychological intervention for depression and anxiety disorders (Clark et al., 2009). There are two tiers of IAPT therapy, depending on clinical severity, and corresponding to NICE steps 2 and 3 for the treatment of depression and anxiety. More intense therapy is delivered by more experienced clinicians in the higher tier. The lower tier provides treatment for the majority of referrals from primary care and other sources.

IAPT represents a public health approach to the treatment of mild to severe depression and anxiety (Layard, 2006; Richards & Suckling, 2009). The rationale for widespread implementation of the IAPT programme, besides aiming to decreasing the prevalence of mental illness in the UK, was that economic gains associated with increased productivity and reemployment of treated individuals would dwarf all costs associated with the programme; that providing psychological therapy to people not now in treatment would result in “the cost to the government to be fully covered by the savings in incapacity benefits and extra taxes that result from more people being able to work” (Layard, Clark, Knapp, & Mayraz, 2007). Layard et al. (2007) also argued that these stepped care, expanded psychological therapies programmes would cover the cost to the government by the extra output in GDP produced by the treated person, savings to the exchequer in incapacity benefits and extra taxes as a result of more people being able to work.

IAPT services have been commissioned throughout England, with more than 300 new therapists recruited for training in the East of England (EoE) alone between 2008 and 2011. By substantially increasing the number of therapists, IAPT is intended to facilitate increased referrals and reduced waiting times, with the potential to increase patient reported satisfaction and reduce self-reported depression and anxiety (CEP, 2006; Layard, 2006). The funding for the IAPT programme was contingent on the successful implementation of a new treatment programme in two demonstration sites: Doncaster in Northern England and Newham in East London. The outcomes of these pilots would be used to argue that the increased funding from the Government could deliver better clinical outcomes in terms of magnitude of improvement and treatment volume to justify the investment (Richards & Suckling, 2009).

A recent evaluation of both demonstration sites indicated that at least 55% of patients who attended at least two sessions (including an assessment interview) recovered and 5% transitioned from unemployment into part- or full-time employment (Clark et al., 2009). Overall, this study demonstrated that the talking therapies model can be effective in the treatment of depression and anxiety. Whilst that recent evaluation reported on clinical outcomes and improvements in employment status, no attempt was made to report on the costs incurred by the programme. The cost of the programme is an important consideration for psychological therapy implementation. Given that IAPT therapy sessions are provided by high and low intensity therapists (subsequently called psychological well-being practitioners or PWPs) who differ markedly in their training and salary costs, there could be a significant difference in the session costs delivered by each types. The cost of a typical course of completed treatment is also an important facet of cost to consider. Now that recovery of patients is an important indicator of IAPT programme's performance, it is crucial to estimate the cost of a recovered patient through the IAPT programme and its activities. This study is an attempt to estimate the cost of session, completed treatment and recovered patient using financial data from 5 Primary Care Trusts (PCTs) in the EoE region.

Section snippets

Methods

IAPT services are based on a stepped-care model: patients receive either high or low intensity interventions, as deemed appropriate by a standard initial assessment (Clark et al., 2009). Initial analysis of outcomes data collected in selected PCTs in EoE also revealed that a significant number of patients transitioned from high intensity to low intensity interventions and vice versa. The cost per session, cost of treatment and cost of recovery associated with these four types of treatment

Results

In total, 10,789 patients completed or ended IAPT treatment for various reasons between 1 April 2009 and 31 March 2010, of whom 21.2% attended only 1 session (Fig. 2). Among those who attended 2 or more sessions, 4844 (44.9%) successfully completed the allotted treatment (i.e., after an agreement between the therapist and patient to end treatment). A significant number of patients dropped out of treatment (n = 1961; 18.2%) and 861 (8%) were found unsuitable for IAPT treatment after attending 2

Key findings

This analysis provides, to the knowledge of the authors, one of the first cost analysis of psychologically based talking therapies in the UK that is based on routine outcome data and actual public sector spending. Financial information on the total spend on IAPT programmes from five PCTs in the EoE region was combined with clinical outcomes to estimate the costs associated with four treatment courses (i.e., remaining in low or high intensity treatment, stepping up or down). Although the IAPT

Conclusion

This is one of the first assessments of costs of talking based psychological therapies in the UK. Results indicate that costs currently compare to previous estimates, and supports the originally proposed model on cost–benefit grounds. We invite replication and additional analyses along with evidence-based discussion about alternative, cost-effective methods of intervention. It is likely that improvements in current IAPT practice cannot occur until current practice is scrutinised and treatment

Financial disclosure

The NIHR Collaboration for Leadership in Applied Health Research & Care (CLAHRC) for Cambridgeshire & Peterborough (http://www.clahrc-cp.nihr.ac.uk) hosted the study and is, itself, hosted by the Cambridgeshire & Peterborough NHS Foundation Trust. All authors and their employers are partners in the CLAHRC. The views expressed in this manuscript are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The funders had no role in study design, data

Ethical approval

The study design for routine analyses of IAPT data in the East of England was reviewed by the National Research and Ethics Service (NRES) that considered the work to be an evaluation of existing services using anonymous clinical data not requiring research ethics approval.

Conflict of Interest

None declared.

Acknowledgements

The authors thank Caroline Lee, Christine Hill and Carol Brayne for comments on an earlier version of the manuscript, and data managers in the participating PCTs for their cooperation and help. The authors also thank the anonymous reviewers for their helpful comments.

References (21)

  • D.M. Clark et al.

    Improving access to psychological therapy: initial evaluation of two UK demonstration sites

    Behaviour Research and Therapy

    (2009)
  • I.M. Cameron et al.

    Psychometric comparison of PHQ-9 and HADS for measuring depression severity in primary care

    British Journal of General Practise

    (2008)
  • The depression report: A new deal for depression and anxiety disorders

    (2006)
  • Press release: Johnson announces £170 million boost to mental health therapies

    (2007)
  • Department of Health

    Improving access to psychological therapies (IAPT) commissioning toolkit

    (2008)
  • A. Gyani et al.

    Enhancing recovery rates in IAPT services: Lessons from analysis of the year one data

    (2011)
  • G. Hammond et al.

    Comparative effectiveness of cognitive therapies delivered Face-to-face or over the telephone: an observational study using propensity methods

    PLoS ONE

    (2012)
  • S. Hollinghurst et al.

    Cost-effectiveness of therapist-delivered online cognitive–behavioural therapy for depression: randomised controlled trial

    The British Journal of Psychiatry

    (2010)
  • R.C. Kessler et al.

    The epidemiology of major depressive disorder: results from the National comorbidity survey replication (NCS-R)

    Journal of the American Medical Association

    (2003)
  • K. Kroenke et al.

    The PHQ-9: validity of a brief depression severity measure

    Journal of General Internal Medicine

    (2001)
There are more references available in the full text version of this article.

Cited by (53)

  • The impact of mental health support for the chronically ill on hospital utilisation: Evidence from the UK

    2022, Social Science and Medicine
    Citation Excerpt :

    IAPT has been shown to be effective in improving mental health outcomes (Clark et al., 2018) with an overall clinical recovery rate of over 50% for those who complete an episode of treatment, and nearly 70% reporting improvement in symptoms (NHS Digital, 2019). However, these results come from uncontrolled pre-post evaluations of services and mixed findings have been reported surrounding the cost-effectiveness of IAPT treatment (Steen, 2020; Mukuria et al., 2013; Radhakrishnan et al., 2013). The current national estimated cost per episode is £680 per patient, implying IAPT is cost effective as it is lower than the £750 per treatment course which has been estimated as part of the economic case for IAPT (Layard et al., 2007).

  • Mental health trajectories of individuals and families following the COVID-19 pandemic: Study protocol of a longitudinal investigation and prevention program

    2021, Mental Health and Prevention
    Citation Excerpt :

    We implement several approaches to increase the efficiency of resources. Studies of randomized trials and national health projects like the “Improving Access to Psychological Treatment” initiative in England demonstrated the feasibility and resource- and cost-effectiveness of stepped care programs as primary care and prevention (Clark, 2011; Radhakrishnan et al., 2013; Van't Veer-Tazelaar et al., 2010). In addition to that, meta-analyses that demonstrate the effectiveness of digital mental health interventions especially in anxiety, depression and insomnia also call for studies investigating the feasibility of digital mental health interventions in real life environments (Adults: Ebert et al., 2015, 2017, 2018; Venkatesan et al., 2020; Richardson et al., 2010b; Children and adolescents: Hollis et al., 2017).

  • Clinical effectiveness and cost minimisation model of Alpha-Stim cranial electrotherapy stimulation in treatment seeking patients with moderate to severe generalised anxiety disorder

    2019, Journal of Affective Disorders
    Citation Excerpt :

    It had a moderate effect size. Remission rates are lower than reported for iCBT in routine IAPT services in the UK (Radhakrishnan et al., 2013); however our sample had substantially higher scores than routinely reported for IAPT services (Radhakrishnan et al., 2013; NHS Digital 2019 ). Approximately 50% of patients on the waiting list for iCBT received iCBT, thereby enabling the NHS IAPT services to treat other patients on the waiting list for iCBT.

  • Dissemination and Implementation of Cognitive Behavioral Therapy for Depression in the Kaiser Permanente Health Care System: Evaluation of Initial Training and Clinical Outcomes

    2019, Behavior Therapy
    Citation Excerpt :

    These very positive training outcomes may, in part, reflect the individualized nature of the training, a specific focus of the current approach to training in CBT. The results with respect to initial patient outcomes reveal that CBT-D was associated with not only clinically significant reductions in depression, but also clinically significant reductions in anxiety, improvements that are consistent with past research and recent outcomes reported by real-world CBT-D training and implementation initiatives conducted within public systems (Karlin et al., 2012; Lopez & Basco, 2015; Radhakrishnan et al., 2013; Simons et al., 2010; Twomey, O’Reilly, & Byrne, 2015). The observed improvements in anxiety provide support for the utility of the treatment for patients with co-occurring generalized anxiety symptoms.

View all citing articles on Scopus
View full text