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Commissioning a service providing cognitive behavioural therapy for the management of common mental health problems

Cognitive behavioural therapy (CBT) is an effective treatment option for many mental health problems and is indicated for people with depression, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and anxiety. The purpose of therapy is to reduce distress or unwanted behaviour by undoing previous learning or by providing new, more adaptive learning experiences.

CBT is one of a broad range of psychotherapies. Other psychotherapies are behaviour therapy, interpersonal therapy, problem-solving therapy, non-directive counselling and short-term psychodynamic psychotherapy. CBT is brief, highly structured, problem orientated and prescriptive, and individuals are active collaborators. The way in which CBT is delivered varies depending on the individual’s needs. For example, it may be delivered by trained therapists who can be from a number of disciplines, including clinical psychologists, mental health nurse specialists and psychiatrists, or via an interactive computer interface - computerised CBT (CCBT). The optimal length of therapy will vary among individuals and conditions.

CBT’s evidence base, short-term nature and economical use of resources have made it attractive to clients, practitioners and service purchasers. However, in many places around the country NHS psychological therapies, including CBT, are either unavailable or subject to significant delays. This is because of the high level of demand, the limited availability of therapists and a lack of clear referral criteria and pathways. Improving access to psychological therapies is the subject of a public service agreement between the Department of Health and the Treasury, and is an NHS Operating Framework 2008/09 ‘vital sign’. The operating framework states that primary care trusts should start preparing for these services being more widely available in the future, and that they should begin planning now how they will implement a stepped care psychological therapies service following the NICE guidelines. The first step for primary care trusts is to carry out a needs assessment of their local population.

Benefits

The potential benefits of robustly commissioning an effective service providing CBT for the management of common mental health problems include:

  • reducing the risk of people proceeding to a more severe form of their condition
  • reducing the suicide risk
  • reducing the number of antidepressant medications prescribed
  • reducing referrals to secondary care services
  • providing access to coping strategies and support as an alternative to taking sick leave from work because of depression
  • retaining employment, even where the individual may suffer from stress, anxiety or depression, and enabling people on benefits to return to work more quickly
  • improving performance and patient-centred clinical care through implementing the recommendations outlined in NICE clinical guidelines CG22 on anxiety, CG23 on depression, CG26 on PTSD, CG31 on OCD and NICE technology appraisal TA97 on CCBT.
  • reducing inequalities and improving access to CBT
  • increasing patient choice, and improving partnership working, patient experience and engagement
  • better value for money, through helping commissioners to manage their commissioning budgets more effectively – this may include opportunities for clinicians to undertake local service redesign to meet local requirements in novel ways.

Key clinical issues

Key clinical issues in providing an effective service offering CBT for the management of common mental health problems are:

  • recognising and accurately diagnosing common mental health problems
  • providing comprehensive assessment and accurately differentiating between people with either mild/moderate depression or severe depression, identifying PTSD despite the presence of comorbidities and assessing the degree of functional impairment of people with OCD
  • ensuring that services providing CBT are integrated with other services for people with depression, OCD, PTSD or anxiety to ensure continuity of care
  • providing a quality assured service.

National priorities

National priorities and initiatives relevant to commissioning a service providing CBT for the management of common mental health problems include:

Although many or all of these priorities may be relevant to the services nationally, your local service redesign may address only one or two of them.