This week’s post is about a technique used as part of cognitive behavioural therapy for people with depression. As you probably know already, symptoms of depression include low mood, low self-esteem, feelings of anxiety and helplessness, and having low motivation and interest in activities which they previously enjoyed.
Behavioural activation focuses on the ‘B’ of the CBT model, in this case on the last symptom in particular – the withdrawal from usual activities and friends. For example, they may start to avoid social engagement and ignore invites from friends or make excuses as to why they can’t meet up, whereas before they would have been happy to go. Although in the short term this avoidance causes a temporary relief, such as a lowering of anxiety, it simply reinforces feelings of low mood or low self-esteem. This maintenance of the condition is illustrated by this diagram below:
Therefore, in order to break this cycle, behavioural activation aims to change the unhelpful behaviours which continue the cycle of low mood. It does this by gradually building up activities that the person can do, which is turn will improve their mood, and lead eventually to them getting back to activities they used to enjoy. This progression is important, as the change in mood is needed before larger behavioural changes can occur.
Key features of Behavioural Activation are as follows (taken from Jacobson et al, 2001):
- Firstly, the model is presented to patients by their clinician, who explain a bit about it and why it works. This is called a treatment ‘rationale’ and it is important for the patient to feel confident that this will work. A good relationship and trust with the therapist is also important.
- Developing treatment goals through collaboration between the patient and the therapist – these goals are new behaviours rather than moods or emotions.
- Analysis of causes and maintenance factors of the depression
- Graded task assignment – e.g. starting with something small such as walking to the corner shop. This is scheduled in between sessions, and a hierarchy is discussed with the therapist.
- Establishing a routine, in the hope this results in improved mood.
Ultimately, the aim of Behavioural Activation is to help the patient re-engage and find joy in activities which they have been avoiding. This will raise mood, and therefore help someone recover from depression.
This week in the UK is Mental Health Awareness Week, so today’s post will be a bit different – what are the main issues about treating mental illness in our society, and how can access to therapy be improved?
Firstly: not enough money is being spent to improve access to mental health services in the UK. Fact. This means not everyone who needs access to treatment gets it, which, as well as having a massive impact on society, has an extreme effect on our economy too.
The statistics are striking: only 25% of people with mental illness are in treatment, compared to almost 100% of people with physical health issues (Layard et al, 2012). And mental illness isn’t rare – the World Health Organisation found that mental illness makes up about 40% of all illness in developed countries. In the UK, 15% of the population of the UK suffer from anxiety or depression, but only 5% of those are in treatment (Depression Report, 2005).
And why are these individuals not receiving treatment? A report carried out by several mental health charities found that 1 in 4 primary care organisations do not offer Cognitive Behavioural Therapy – the treatment recommended by NICE for all anxiety disorders and depression. It is therefore clear that more needs to be done to improve access to therapy in the UK.
However, once a patient has been offered therapy, the problems of lack of funding do not go away. Waiting lists can be as long as several months, by which the problems could have got worse. This is another area where there is a massive disparity between mental and physical health services.
Therefore, it seems obvious that more money should be invested in mental health services within the NHS. This comes at a time where the NHS budget is stretched to the limit, and the government are looking at cutting funds to public services. And here’s the clever bit: improving access in mental health services would pay for itself.
Let’s look at the economic cost of mental illness in the UK. In 2005, it was estimated that anxiety and depression cost the UK about £17 billion per year. About half of disability benefits are paid to people with mental illness. One study found that less than 25% of people with long term mental illness have a job, compared to about 75% of the rest of the working-age population. Therefore, this results in a massive loss of revenue from taxes, as well as increased expenditure on benefits and sick pay.
Even when people are at work, mental illness can reduce productivity and so cost the company money. A NICE study found that improving management of mental health in the workplace could save 30% of reduced productivity and sick pay costs. If a company has 1,000 employees, this equates to a saving of £250,000 per year.
Mental health also has a significant impact on our physical health, which causes more pressure on the health service. Hutter et al (2010) found that individuals with mental health problems use 60% more physical health services than people who are equally ill but do not have mental health problems. This costs the NHS about £10 billion per year. These figures are striking, and show more money, not less, needs to be invested in mental health services.
The massive economic costs of mental illness are clear, but what about savings from improving access to treatment? Layard et al (2007) found that its costs £630 to treat a patient, but this leads to £4,700 in benefits to society in the form of more people off disability benefits and back as work, so paying more taxes, and less spent on physical health services and sick days.
Fortunately, things are being done to make mental health treatment more accessible. For example, Improving Access to Psychological Therapies (IAPT), which aims to train more therapists for specialised local services. So far, this initiative has treated about 756,000 patients a year, with 45% recovering completely, 60% showing a reduction in symptoms, and 5% being well enough to come off sick pay and benefits and return to work.
This just shows the positive impact of expanding mental health services in the UK, and making treatment available for those who need it. At a time when the country is undergoing a change in government, these issues need to be remembered and prioritised. Even with cuts, and less money available, these statistics show that more money, not less, needs to be spent on mental health services in the UK.