Psychotherapy Advancing the Accessibility of Psychotherapy: Learning From Our International Colleagues Although the Affordable Care Act has theoretically made access to mental health care possible for all patients, the United States continues to lag behind other countries with respect to the provision of psychotherapeutic treatments. In the United Kingdom, for example, substantial resources have been committed to increase the availability of effective psychotherapies, particularly for depression and anxiety disorders. This development required a significant deployment of resources, with more than one billion dollars committed over the course of 7 years (2008–2015). Over 6,000 therapists have been trained and are currently being deployed in specialized local services to treat patients with depression and anxiety. A second phase of the initiative aims to bring psychotherapeutic treatment to patients with schizophrenia, bipolar disorder, and borderline personality disorder. Psychotherapy advocates in the United States may be more successful in advocating for such treatments by using similar methods to influence legislators and insurers. (Journal of Psychiatric
DONNA M. SUDAK, MD
Similar to the case made by the GAP studies, the British initiative relied on studies of the effectiveness and economic benefits of psychotherapy, in this instance largely cognitive and behavioral therapy. Evaluation of effectiveness is built into the project design. Other nations also are far ahead of the United States in providing access to psychotherapy. The work Dr. Sudak reports should be a wake-up call to the redesigners of the American health care system. Norman A. Clemens, MD Psychotherapy Column Editor Although the Affordable Care Act has theoretically made access to mental health care possible for all patients, the United States continues to lag behind other countries with respect to the provision of psychotherapeutic treatments. In the United Kingdom, for example, substantial resources have been committed to increase the availability of effective psychotherapies, particularly for depression and anxiety disorders.
Practice 2015;21:150–153) KEY WORDS: psychotherapy, availability, depression, anxiety, schizophrenia, bipolar disorder, borderline personality disorder, Affordable Care Act, United Kingdom
Psychotherapy is now well established as an evidence-based treatment for a wide range of psychiatric disorders, but lack of funding for effective psychotherapy services has impeded its widespread availability to those who need it in the United States. In a recent special issue of Psychodynamic Psychotherapy, the Psychotherapy Committee of the Group for the Advancement of Psychiatry (GAP) published a comprehensive collection of papers on the effect of mandated mental health parity and the Affordable Care Act on access to psychodynamic psychotherapy. Donna Sudak here describes how the United Kingdom has successfully deployed substantial resources to make evidence-based psychotherapy available for depression and anxiety disorders.
150
March 2015
The Improving Access to Psychological Therapies (IAPT) Initiative The National Health Service in the United Kingdom has a division called the National Institute for Health and Care Excellence (NICE), the purpose of which is to review the evidence concerning treatments that are available for particular disorders. NICE provides an accepted database of recommended treatments for depression and anxiety; it recommends individual or group cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), behavioral activation, behavioral couples therapy, counseling, and short-term psychodynamic therapy for mild to moderate depression.1 Despite such recommendations, fewer than 5% of patients had access to empirically supported psyDr. Sudak is Professor of Psychiatry, Senior Associate Training Director, and Director of Psychotherapy Training, Drexel University College of Medicine, Philadelphia, PA. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/01.pra.0000462607.25349.ab
Journal of Psychiatric Practice Vol. 21, No. 2
Copyright © Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Psychotherapy chotherapy before 2008,2 even though treatment with psychotherapy was preferred to medication by patients at a ratio of 3 to 1.3 Since 2008, the United Kingdom has committed substantial resources to increase the availability of effective psychotherapies, particularly for depression and anxiety disorders, with more than one billion dollars allocated for this purpose over 7 years (2008–2015). More than 6,000 therapists have been trained and are currently being deployed in specialized local services to treat patients with depression and anxiety. A second phase of the initiative aims to bring psychotherapeutic treatment to patients with schizophrenia, bipolar disorder, and borderline personality disorder. Thrive: The Power of Evidence-Based Psychological Therapies, written by Richard Layard and David M. Clark and published in 2014, chronicles this process and presents a cogent argument for the provision of effective psychotherapy.4 Clark, a clinical psychologist, partnered with Layard, an economist with a particular interest in mental health. Together they presented the evidence for the effectiveness and durability of psychotherapeutic treatment and how providing effective care would essentially pay for itself and ultimately save money. Their powerful argument for the provision of psychotherapy for mental illness was based on principles of justice and parity. First, they presented data about the incidence of depression and anxiety. Mental illness is responsible for approximately 28% of the morbidity from disease worldwide (half of which is due to depression and anxiety), compared with 6% caused by cardiovascular disease.5 Far more patients are in treatment for medical illnesses, however, because of discriminatory funding and lack of access for mental health treatment. Stigma regarding psychiatric illness and people’s reluctance to seek care are other factors that play a role in reduced funding. Layard and Clark next presented data regarding the effectiveness of psychological treatments for depression and anxiety and the costs of providing such treatment. Multiple studies exist regarding the effective and durable outcomes achieved by psychotherapeutic interventions and how they can improve patient functioning.6−9 Approaching funders and policy makers with the economic impact of such interventions along with an accurate assessment of the cost of treatment and a guarantee of the provision of outcome data was even more effective when future productivity was considered. Studies have
Journal of Psychiatric Practice Vol. 21, No. 2
clearly demonstrated, for example, that there is a significant increase in employment after CBT for depression,7,10 and there is a strong argument to be made on that basis alone. However, Layard and Clark provided a detailed analysis of the costs of not treating such problems from the standpoint of lost productivity (decreased life expectancy, fewer taxes paid, increased work in the economy, suicide, costs of poor health and increased health care utilization, decreased productivity of loved ones who are caretakers, disability and welfare payments), and an assessment of the costs of a program designed to provide measurement-based care. Furthermore, a study that followed patients treated in the IAPT program since its inception matched with patients who were not treated showed that health care costs for physical illnesses declined by £1050 per patient4 (p. 188).11 A major “selling point” to the government of the United Kingdom was the commitment to provide complete data regarding outcomes. So the “take home” lesson for advocates in the United States is to provide data to politicians regarding the effectiveness and durability of psychotherapy for depression and anxiety, an economic argument for the implementation of such care, and measurement-based treatment to assess efficacy and savings to advance the provision of care. This means that individual practitioners must have a mechanism to collect outcome measures from session to session (cf, Mark Zimmerman’s website www.outcometracker.org) to provide funders evidence of the effectiveness of psychotherapeutic treatments. Presenting an economic argument for psychotherapy was more effective when it was discussed both privately with politicians and publically in the press. The economic cost of depression and anxiety in the United Kingdom was calculated to be £17,000,000,000 ($25,908,510,000).12 Beginning with Prime Minister Tony Blair in 2005, every political party has included psychological therapy in their election platforms4 (p. 198). Thus, Layard and Clark obtained agreement for funding that was guaranteed irrespective of any governmental changes (ie, whichever party is in power) to ensure continuity of the program. Key Principles of Training and Treatment Provided by IAPT The model developed to establish clinical services included several principles to maintain fidelity and
March 2015
Copyright © Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
151
Psychotherapy quality: delivery of therapies approved by NICE by fully trained therapists who are supervised weekly by qualified supervisors. Others have argued that this form of service delivery is less viable as a model for public health needs and that guided self-help and Internet-based training are more effective strategies.13,14 Self-referral to services is permitted (a departure from usual practice in the United Kingdom), and outcomes are measured at every session.15 Demonstration sites were initially developed to help determine the most effective way of managing the national plan.16 Stepped-care was determined to be the economically most effective form of triage, with guided self-help, and unemployment and social service advisors providing for less significantly ill patients, with step-up to more intensive treatment if these initial interventions fail. Therapists trained in providing high intensity therapies were made available for more significantly ill patients or patients whose conditions were refractory to initial treatment. Such demonstration projects showed a 52% recovery rate from depression and anxiety, with gains maintained at least 9 months after therapy ended.16 After the initial training of 3600 therapists before 2011, an additional 2400 have been trained to be deployed in the new clinical services with the goal of treating anxiety and depression, initially with CBT, but the project also intends to add behavioral marital therapy and interpersonal therapy.1 Recovery targets have been set at 50% and session to session outcome measures are consistently employed. By 2012, nearly 1 million people had used the new services and over 442,000 patients had finished treatment.11 Of the patients referred for treatment, 45% recovered and 60% reliably improved; thus far 5% have stopped using sick pay or benefits4 (p. 194). England is not alone in providing access to psychotherapy as a new method of cost saving within the national health service. Germany spends half of the overall funds allocated by the public health insurance system for procedures in neurology and psychiatry for the provision of psychotherapy,17 including funding for CBT, psychodynamic psychotherapy, and psychoanalysis. In April 2010, CBT for mood disorders became a covered service in Japan.18 In a Commentary in the American Journal of Psychiatry in 2013, Weissman noted that the developing world has been more creative in disseminating psychotherapy (mostly through task shifting—that is, redistributing tasks throughout the available healthcare team rather
152
March 2015
than trying to train sufficient numbers of new experts) and that it has found it to be economical and feasible even as psychotherapy becomes less available in the United States.19 Such programs should serve as a model for advocacy by academic leaders and public psychiatry groups and inform our training and treatment efforts. Mental health conditions are expensive, burdensome, and deadly. We should emulate our counterparts in other nations. Arguing the economic value of psychotherapy may provide sufficient leverage to obtain public support for the dissemination of such an effective treatment.
References 1. Clark DM. Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: the IAPT experience. Int Rev Psychiatry. 2011;23:318–327. 2. McManus S, Meltzer H, Brugha T, et al, editors. Adult Psychiatric Morbidity in England, 2007: Results of a Household Survey. Prepared by the National Centre for Social Research and the Department of Health Sciences, University of Leicester for the National Health Service Information Centre. London: NHS Information Centre; 2009 (available at http://www.hscic.gov.uk/article/2021 /Website-Search?productid=151&q=Adult+Psychiatric +Morbidity+in+England%2c+2007&sort=Relevance&size= 10&page=1&area=both#top, accessed February 1, 2015). 3. Kwan BM, Dimidjian S, Rizvi SL. Treatment preference, engagement, and clinical improvement in pharmacotherapy versus psychotherapy for depression. Behav Res Ther. 2010;48:799–804. 4. Layard R, Clark DM. Thrive: The Power of Evidence-Based Psychological Therapies. London: Penguin Books; 2014. 5. Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990−2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859): 2163−2196. 6. Lindfors O, Knekt P, Heinonen E, et al. The effectiveness of short- and long-term psychotherapy on personality functioning during a 5-year follow-up. J Affect Disord. 2015;173:31−38. 7. McCrone P, Knapp M, Proudfoot J, et al. Cost-effectiveness of computerised cognitive-behavioural therapy for anxiety and depression in primary care: randomised controlled trial. Br J Psychiatry. 2004;185:55−62. 8. Hollon SD, Stewart MO, Strunk D. Enduring effects for cognitive behavioral therapy in the treatment of depression and anxiety. Annu Rev Psychol. 2006;57:285–315. 9. Hofmann SG, Wu JQ, Boettcher H.. Effect of cognitivebehavioral therapy for anxiety disorders on quality of life: a meta-analysis. J Consult Clin Psychol. 2014;82:375−391. 10. Proudfoot J, Guest D, Carson J, et al. Effect of cognitivebehavioural training on job-finding among long-term
Journal of Psychiatric Practice Vol. 21, No. 2
Copyright © Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Psychotherapy unemployed people. Lancet. 1997;350(9071):96−100. 11. Department of Health. IAPT three-year report: the first million patients. November, 2012 (available at http://www.iapt.nhs.uk/silo/files/iapt-3-year-report.pdf, accessed February 1, 2015). 12. Layard R. Clark D, Knapp M, et al. G. Cost-benefit analysis of psychological therapy Natl Inst Econ Rev. 2007; 202:90–98. 13. Fairburn CG, Patel V. The global dissemination of psychological treatments: a road map for research and practice. Am J Psychiatry. 2014;171:495−498 14. Cuijpers P. Psychotherapies for adult depression: recent developments. Curr Opin Psychiatry. 2015;28:24–29. 15. Gyani A, Shafran R, Layard R, et al. Enhancing recovery
Journal of Psychiatric Practice Vol. 21, No. 2
16.
17.
18.
19.
rates: lessons from year one of IAPT. Behav Res Ther. 2013;51:597−606. Clark DM, Layard R, Smithies R, et al. Improving access to psychological therapy: initial evaluation of two UK demonstration sites. Behav Res Ther. 2009;47:910-920. Schnell K, Herpertz SC. Psychotherapy in psychiatry: the current situation and future directions in Germany. Eur Arch Psychiatry Clin Neurosci. 2011;261(Suppl 2): S129−S134. Ono Y, Furukawa TA, Shimizu E, et al. Current status of research on cognitive therapy/cognitive behavior therapy in Japan. Psychiatry Clin Neurosci. 2011;65:121−129. Weissman MM. Psychotherapy: a paradox. Am J Psychiatry. 2013;170:712–715.
March 2015
Copyright © Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
153
DONNA M. SUDAK, MD
Similar to the case made by the GAP studies, the British initiative relied on studies of the effectiveness and economic benefits of psychotherapy, in this instance largely cognitive and behavioral therapy. Evaluation of effectiveness is built into the project design. Other nations also are far ahead of the United States in providing access to psychotherapy. The work Dr. Sudak reports should be a wake-up call to the redesigners of the American health care system. Norman A. Clemens, MD Psychotherapy Column Editor Although the Affordable Care Act has theoretically made access to mental health care possible for all patients, the United States continues to lag behind other countries with respect to the provision of psychotherapeutic treatments. In the United Kingdom, for example, substantial resources have been committed to increase the availability of effective psychotherapies, particularly for depression and anxiety disorders.
Practice 2015;21:150–153) KEY WORDS: psychotherapy, availability, depression, anxiety, schizophrenia, bipolar disorder, borderline personality disorder, Affordable Care Act, United Kingdom
Psychotherapy is now well established as an evidence-based treatment for a wide range of psychiatric disorders, but lack of funding for effective psychotherapy services has impeded its widespread availability to those who need it in the United States. In a recent special issue of Psychodynamic Psychotherapy, the Psychotherapy Committee of the Group for the Advancement of Psychiatry (GAP) published a comprehensive collection of papers on the effect of mandated mental health parity and the Affordable Care Act on access to psychodynamic psychotherapy. Donna Sudak here describes how the United Kingdom has successfully deployed substantial resources to make evidence-based psychotherapy available for depression and anxiety disorders.
150
March 2015
The Improving Access to Psychological Therapies (IAPT) Initiative The National Health Service in the United Kingdom has a division called the National Institute for Health and Care Excellence (NICE), the purpose of which is to review the evidence concerning treatments that are available for particular disorders. NICE provides an accepted database of recommended treatments for depression and anxiety; it recommends individual or group cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), behavioral activation, behavioral couples therapy, counseling, and short-term psychodynamic therapy for mild to moderate depression.1 Despite such recommendations, fewer than 5% of patients had access to empirically supported psyDr. Sudak is Professor of Psychiatry, Senior Associate Training Director, and Director of Psychotherapy Training, Drexel University College of Medicine, Philadelphia, PA. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/01.pra.0000462607.25349.ab
Journal of Psychiatric Practice Vol. 21, No. 2
Copyright © Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Psychotherapy chotherapy before 2008,2 even though treatment with psychotherapy was preferred to medication by patients at a ratio of 3 to 1.3 Since 2008, the United Kingdom has committed substantial resources to increase the availability of effective psychotherapies, particularly for depression and anxiety disorders, with more than one billion dollars allocated for this purpose over 7 years (2008–2015). More than 6,000 therapists have been trained and are currently being deployed in specialized local services to treat patients with depression and anxiety. A second phase of the initiative aims to bring psychotherapeutic treatment to patients with schizophrenia, bipolar disorder, and borderline personality disorder. Thrive: The Power of Evidence-Based Psychological Therapies, written by Richard Layard and David M. Clark and published in 2014, chronicles this process and presents a cogent argument for the provision of effective psychotherapy.4 Clark, a clinical psychologist, partnered with Layard, an economist with a particular interest in mental health. Together they presented the evidence for the effectiveness and durability of psychotherapeutic treatment and how providing effective care would essentially pay for itself and ultimately save money. Their powerful argument for the provision of psychotherapy for mental illness was based on principles of justice and parity. First, they presented data about the incidence of depression and anxiety. Mental illness is responsible for approximately 28% of the morbidity from disease worldwide (half of which is due to depression and anxiety), compared with 6% caused by cardiovascular disease.5 Far more patients are in treatment for medical illnesses, however, because of discriminatory funding and lack of access for mental health treatment. Stigma regarding psychiatric illness and people’s reluctance to seek care are other factors that play a role in reduced funding. Layard and Clark next presented data regarding the effectiveness of psychological treatments for depression and anxiety and the costs of providing such treatment. Multiple studies exist regarding the effective and durable outcomes achieved by psychotherapeutic interventions and how they can improve patient functioning.6−9 Approaching funders and policy makers with the economic impact of such interventions along with an accurate assessment of the cost of treatment and a guarantee of the provision of outcome data was even more effective when future productivity was considered. Studies have
Journal of Psychiatric Practice Vol. 21, No. 2
clearly demonstrated, for example, that there is a significant increase in employment after CBT for depression,7,10 and there is a strong argument to be made on that basis alone. However, Layard and Clark provided a detailed analysis of the costs of not treating such problems from the standpoint of lost productivity (decreased life expectancy, fewer taxes paid, increased work in the economy, suicide, costs of poor health and increased health care utilization, decreased productivity of loved ones who are caretakers, disability and welfare payments), and an assessment of the costs of a program designed to provide measurement-based care. Furthermore, a study that followed patients treated in the IAPT program since its inception matched with patients who were not treated showed that health care costs for physical illnesses declined by £1050 per patient4 (p. 188).11 A major “selling point” to the government of the United Kingdom was the commitment to provide complete data regarding outcomes. So the “take home” lesson for advocates in the United States is to provide data to politicians regarding the effectiveness and durability of psychotherapy for depression and anxiety, an economic argument for the implementation of such care, and measurement-based treatment to assess efficacy and savings to advance the provision of care. This means that individual practitioners must have a mechanism to collect outcome measures from session to session (cf, Mark Zimmerman’s website www.outcometracker.org) to provide funders evidence of the effectiveness of psychotherapeutic treatments. Presenting an economic argument for psychotherapy was more effective when it was discussed both privately with politicians and publically in the press. The economic cost of depression and anxiety in the United Kingdom was calculated to be £17,000,000,000 ($25,908,510,000).12 Beginning with Prime Minister Tony Blair in 2005, every political party has included psychological therapy in their election platforms4 (p. 198). Thus, Layard and Clark obtained agreement for funding that was guaranteed irrespective of any governmental changes (ie, whichever party is in power) to ensure continuity of the program. Key Principles of Training and Treatment Provided by IAPT The model developed to establish clinical services included several principles to maintain fidelity and
March 2015
Copyright © Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
151
Psychotherapy quality: delivery of therapies approved by NICE by fully trained therapists who are supervised weekly by qualified supervisors. Others have argued that this form of service delivery is less viable as a model for public health needs and that guided self-help and Internet-based training are more effective strategies.13,14 Self-referral to services is permitted (a departure from usual practice in the United Kingdom), and outcomes are measured at every session.15 Demonstration sites were initially developed to help determine the most effective way of managing the national plan.16 Stepped-care was determined to be the economically most effective form of triage, with guided self-help, and unemployment and social service advisors providing for less significantly ill patients, with step-up to more intensive treatment if these initial interventions fail. Therapists trained in providing high intensity therapies were made available for more significantly ill patients or patients whose conditions were refractory to initial treatment. Such demonstration projects showed a 52% recovery rate from depression and anxiety, with gains maintained at least 9 months after therapy ended.16 After the initial training of 3600 therapists before 2011, an additional 2400 have been trained to be deployed in the new clinical services with the goal of treating anxiety and depression, initially with CBT, but the project also intends to add behavioral marital therapy and interpersonal therapy.1 Recovery targets have been set at 50% and session to session outcome measures are consistently employed. By 2012, nearly 1 million people had used the new services and over 442,000 patients had finished treatment.11 Of the patients referred for treatment, 45% recovered and 60% reliably improved; thus far 5% have stopped using sick pay or benefits4 (p. 194). England is not alone in providing access to psychotherapy as a new method of cost saving within the national health service. Germany spends half of the overall funds allocated by the public health insurance system for procedures in neurology and psychiatry for the provision of psychotherapy,17 including funding for CBT, psychodynamic psychotherapy, and psychoanalysis. In April 2010, CBT for mood disorders became a covered service in Japan.18 In a Commentary in the American Journal of Psychiatry in 2013, Weissman noted that the developing world has been more creative in disseminating psychotherapy (mostly through task shifting—that is, redistributing tasks throughout the available healthcare team rather
152
March 2015
than trying to train sufficient numbers of new experts) and that it has found it to be economical and feasible even as psychotherapy becomes less available in the United States.19 Such programs should serve as a model for advocacy by academic leaders and public psychiatry groups and inform our training and treatment efforts. Mental health conditions are expensive, burdensome, and deadly. We should emulate our counterparts in other nations. Arguing the economic value of psychotherapy may provide sufficient leverage to obtain public support for the dissemination of such an effective treatment.
References 1. Clark DM. Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: the IAPT experience. Int Rev Psychiatry. 2011;23:318–327. 2. McManus S, Meltzer H, Brugha T, et al, editors. Adult Psychiatric Morbidity in England, 2007: Results of a Household Survey. Prepared by the National Centre for Social Research and the Department of Health Sciences, University of Leicester for the National Health Service Information Centre. London: NHS Information Centre; 2009 (available at http://www.hscic.gov.uk/article/2021 /Website-Search?productid=151&q=Adult+Psychiatric +Morbidity+in+England%2c+2007&sort=Relevance&size= 10&page=1&area=both#top, accessed February 1, 2015). 3. Kwan BM, Dimidjian S, Rizvi SL. Treatment preference, engagement, and clinical improvement in pharmacotherapy versus psychotherapy for depression. Behav Res Ther. 2010;48:799–804. 4. Layard R, Clark DM. Thrive: The Power of Evidence-Based Psychological Therapies. London: Penguin Books; 2014. 5. Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990−2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859): 2163−2196. 6. Lindfors O, Knekt P, Heinonen E, et al. The effectiveness of short- and long-term psychotherapy on personality functioning during a 5-year follow-up. J Affect Disord. 2015;173:31−38. 7. McCrone P, Knapp M, Proudfoot J, et al. Cost-effectiveness of computerised cognitive-behavioural therapy for anxiety and depression in primary care: randomised controlled trial. Br J Psychiatry. 2004;185:55−62. 8. Hollon SD, Stewart MO, Strunk D. Enduring effects for cognitive behavioral therapy in the treatment of depression and anxiety. Annu Rev Psychol. 2006;57:285–315. 9. Hofmann SG, Wu JQ, Boettcher H.. Effect of cognitivebehavioral therapy for anxiety disorders on quality of life: a meta-analysis. J Consult Clin Psychol. 2014;82:375−391. 10. Proudfoot J, Guest D, Carson J, et al. Effect of cognitivebehavioural training on job-finding among long-term
Journal of Psychiatric Practice Vol. 21, No. 2
Copyright © Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Psychotherapy unemployed people. Lancet. 1997;350(9071):96−100. 11. Department of Health. IAPT three-year report: the first million patients. November, 2012 (available at http://www.iapt.nhs.uk/silo/files/iapt-3-year-report.pdf, accessed February 1, 2015). 12. Layard R. Clark D, Knapp M, et al. G. Cost-benefit analysis of psychological therapy Natl Inst Econ Rev. 2007; 202:90–98. 13. Fairburn CG, Patel V. The global dissemination of psychological treatments: a road map for research and practice. Am J Psychiatry. 2014;171:495−498 14. Cuijpers P. Psychotherapies for adult depression: recent developments. Curr Opin Psychiatry. 2015;28:24–29. 15. Gyani A, Shafran R, Layard R, et al. Enhancing recovery
Journal of Psychiatric Practice Vol. 21, No. 2
16.
17.
18.
19.
rates: lessons from year one of IAPT. Behav Res Ther. 2013;51:597−606. Clark DM, Layard R, Smithies R, et al. Improving access to psychological therapy: initial evaluation of two UK demonstration sites. Behav Res Ther. 2009;47:910-920. Schnell K, Herpertz SC. Psychotherapy in psychiatry: the current situation and future directions in Germany. Eur Arch Psychiatry Clin Neurosci. 2011;261(Suppl 2): S129−S134. Ono Y, Furukawa TA, Shimizu E, et al. Current status of research on cognitive therapy/cognitive behavior therapy in Japan. Psychiatry Clin Neurosci. 2011;65:121−129. Weissman MM. Psychotherapy: a paradox. Am J Psychiatry. 2013;170:712–715.
March 2015
Copyright © Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
153
