午夜福利1000集合

Your book is about the mental health initiative you two fought to start. Who is the book for?
Richard Layard: Everyone. We hope it will be a bestseller. David Clark: We want people to realise where science has got us to: people whose lives might otherwise be ruined by long-term mental health problems can benefit from the latest psychological treatments, and many can have their lives transformed. If you get treatment in your 20s and 30s, that means you鈥檝e got 50 years of a very different life.

How big a problem is the undertreatment of mental illness?
RL: In rich countries one in five people suffer a mental illness, mostly depression or anxiety disorders. Mental illness accounts for 38 per cent of all illness and even more for people of working age. Yet in most rich countries it gets under 10 per cent of healthcare expenditure.

Coming from outside psychology, as an economist, I was shocked. Throughout the rich world, less than one-third of people with common mental disorders are in treatment; . This difference is an outrage. There are people who have problems, here and now, who could be treated and are not being treated.

Why don鈥檛 people get treatment?
DC: Part of it is because health authorities and doctors still do not realise how powerful and cost-effective the treatments are. There鈥檚 also a lot of stigma about mental health, which makes people with mental illness less likely to seek treatment. That is probably made even worse because many don鈥檛 know that there are effective treatments waiting for them. These are problems we set out to address with the UK initiative we proposed, Improving Access to Psychological Therapies (IAPT). In the last 30 years there have been major advancements in psychological treatment, but they largely have not been acted on in clinical practice.

Why has clinical practice lagged behind?
DC: There are lots of reasons. Among them, there鈥檚 this very unfortunate term 鈥渢alking therapies鈥�. Everyone hears that and thinks: 鈥淥h, it鈥檚 just like having a chat with someone who鈥檚 nice.鈥� People think it would be a nice thing to have, but that it can鈥檛 be very effective.

Of course, these therapies aren鈥檛 like that. They are based on science, they are tailored to and differ between conditions, and they have evolved enormously on the basis of research about the underlying psychological processes.

What are the consequences of undertreatment?
RL: Among people who are least satisfied with their lives, the biggest cause is poor mental health. These problems affect people in every social class and have huge costs. They also cause low effectiveness at work, family break-up, crime and a host of other problems.

The programme started in England in 2008. Six years on, has it made a difference?
DC: Last year more than 700,000 people were seen through IAPT services, most of whom would not otherwise get any psychological therapy. In services with experienced staff, about two-thirds of people who receive a course of treatment show reliable improvement and close to 50 per cent recover.

What treatment strategies work well?
DC: Initially the focus of the IAPT programme was cognitive behavioural therapy. CBT is recommended for depression and all anxiety disorders by the UK鈥檚 National Institute for 午夜福利1000集合 and Care Excellence (NICE). For mild to moderate depression, NICE also recommends treatments such as counselling and couples therapy, so those are offered as well. This is all about evidence-based treatment. CBT is backed by the most evidence, but it鈥檚 not the only show in town.

What makes CBT so effective?
DC: There is emphasis on having an empathic, supportive therapist. But it鈥檚 called CBT because it focuses on thoughts (cognitions) and behaviours. The key idea is that when people have emotional problems, negative patterns of thinking 鈥� and the way these influence behaviour 鈥� are what keep the problems going.

How would you use it to treat social anxiety, say?
DC: People with this condition have distorted mental images of how they appear to others. One way CBT might deal with this is to video their interactions, then have them compare the video with their images of themselves.

Your behaviour also changes if you鈥檙e frightened of talking to people. If I鈥檓 worried you might think what I say is stupid, chances are, while we鈥檙e talking, I鈥檇 be lost in my head memorising things I鈥檝e said. So what I鈥檓 doing to manage my anxiety actually gives the impression that I鈥檓 not interested in you. In therapy you help people discover that such mental strategies can make things worse, and encourage them to drop those strategies.

How do you know if it鈥檚 working?
RL: Each time someone is seen, they complete a simple measure of anxiety and depression DC: Prior to this initiative, you couldn鈥檛 go to any mental health service and ask: 鈥淚f I came to you to treat my anxiety or depression, what is my chance of recovery?鈥� They didn鈥檛 have complete enough data to answer the question. In just the last three months, about 85,000 people completed a course of treatment with IAPT, and there is pre and post-treatment outcome data on 98 per cent of them.

This has never happened anywhere in the world. It is a revolution. Now those who commission mental healthcare are realising you can set goals based on outcomes 鈥� not for reduced waiting times or more people coming in, but for whether people actually get better.

鈥淭his has never happened anywhere in the world. It is a revolution鈥�

How long does it take to make a difference for one person 鈥� and how much does it cost?
RL: For depression and anxiety disorders, NICE guidelines suggest that about half of people will recover within 10 sessions. So far for IAPT, the average cost is about 拢650 per person. This is not expensive treatment. Moreover, it can prevent public spending on the disability that mental illness can lead to. Our case is that these treatments would actually cost the UK nothing if they were provided more widely.

How much does mental illness cost societies?
RL: For any advanced country, it鈥檚 about 8 per cent of GDP. In the UK, the estimate is nearly 拢130 billion. There are now laws here and in the US that require equal esteem for mental and physical health, but we鈥檙e still nowhere near truly equal access to treatment.

In the UK鈥檚 National 午夜福利1000集合 Service, treatments are still not provided to NICE guidelines. In the US, health insurers often offer just six sessions of psychological therapy 鈥� then you have to reapply if you need more. That鈥檚 like saying if a surgical operation takes over an hour, please reapply to continue.

It seems you still have a battle ahead. Why are things moving so slowly?
RL: The problem is that there鈥檚 no constituency. It鈥檚 less a matter of opposition than not enough people making the proposition, largely because of stigma associated with mental illness. People will fight for more resources for cancer or heart disease. But when it comes to mental illness, there鈥檚 no effective lobby.

What could change this?
RL: It requires an uprising by the general public. If ill people themselves are not able to protest by virtue of their illness, we need to hear much more from their relatives, friends and colleagues. Where healthcare is provided in a democracy, politicians respond to the number of letters that make the point.

This article appeared in print under the headline 鈥淎 different life is possible鈥�