The Damaging Consequences of Not Offering The Best Mental Health Treatment Initially

many will vote with their feet when it comes to further treatment from the same source. Stepped care is the treatment model adopted by the UK Government’s Improving Access to Psychological Therapies (IAPT) Programme. A third (34%) of those who have low intensity therapy are stepped up to high intensity city, according to the IAPT Manual 2021, but the Manual cautions there is considerable local variation in this figure. The question is why? This does not sound like clients following well-defined pathways. As far as I can ascertain IAPT does not publish a recovery rate from low intensity alone, so it is not known what proportion haemorrhage from low intensity.  IAPT is the only show in Town for most people so it is not surprising that when treatment fails some return. For every 2 people referred to IAPT 1 person is attending for between their second and tenth plus courses of treatment – a revolving door. [Following a Freedom of Information Request from Dr Elisabeth Cotton in 2018, it appears that 1.5 million people were referred to IAPT between 2 and 10 or more occasions in a 6 year period (2012-2018), with 3.2 million people referred just once].



What is going on here? NHS England is replete with the following luminaries according to the IAPT Manual (2021), so it is no surprise that there has been no publicly funded independent audit of the Service:

Current NHS England team

Sarah Holloway, Head of Mental Health, NHS England
Xanthe Townend, Programme Lead – IAPT & Dementia, NHS England

David M. Clark, Professor and Chair of Experimental Psychology, University of Oxford; National Clinical and Informatics Adviser for IAPT

Adrian Whittington, National Lead for Psychological Professions, NHSE/I and HEE; IAPT National Clinical Advisor: Education

Jullie Tran Graham, Senior IAPT Programme Manager
Hayley Matthews, IAPT Programme Manager, NHS England Andrew Armitage, IAPT Senior Project Manager, NHS England Sarah Wood, IAPT Project Manager, NHS England

 It appears common sense for IAPT to offer the least costly service first e.g computer assisted therapy and then progress clients to the more costly face to face service if the minimalist intervention has not worked. But IAPT have borrowed from medical care a modus operandi that is not fit for purpose in mental health. For example there is evidence that for some with back pain, physiotherapy will resolve  problems and is the sensible first line treatment, with progression to the costly surgical interventions if physiotherapy does not suffice. But low intensity psychological therapy does not have the evidence base of physiotherapy. This opens up the likelihood that LI will fail to return the client to their best functioning.  Approx a third of clients (37%) receive low intensity only and a third (29%) high intensity only.


The mental health clients take on a failed  first line treatment is likely to involve personalisation e.g  ‘I am stupid, couldn’t quite get what was being asked to do’ and arbitrary inferences e.g ‘I shouldn’t have expected anything would work with me, just my luck’. This is quite different to how most people would likely respond to a failed first line physical intervention. For mental health treatment it may be the the best treatment should be provided first. At a minimum clients should be informed that they are consenting to what is known to be second best.


Dr Mike Scott