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

Service components

The key components of a service providing cognitive behavioural therapy (CBT) for the management of common mental health problems are:

• recognising and diagnosing common mental health problems
• using stepped care
• developing a high-quality service providing CBT.

Recognising and diagnosing

The recognition and diagnosis of common mental health problems can be challenging. The NICE clinical guidelines make recommendations for accurately diagnosing patients presenting with depression, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and anxiety. Commissioners will wish to ensure that adequate arrangements are in place so that patients can be properly diagnosed. It is important as part of the diagnostic process to assess the severity of the patient's illness as this determines the intensity of intervention recommended by the guidance. See a summary of CBT interventions recommended by NICE guidance.

Stepped care

The NICE clinical guidelines for the management of depression and anxiety but not PTSD, and the treatment of OCD, follow a stepped care model. Stepped care provides a framework in which the provision of services can be organised to support patients, carers and healthcare professionals to identify and access the most effective, but least intrusive, intervention appropriate to a person's needs.

The intervention given in stepped care models ranges from ‘low intensity' to ‘high intensity'. Relatively brief interventions provided at step 2 are often described as low-intensity treatment. Treatment provided at step 3 for patients with more severe symptoms or who have not responded to low-intensity treatment is known as high intensity. It is expected that many patients will have had access to treatments on lower steps before receiving treatments from higher steps. Starting treatments on lower steps may produce several benefits. For example, where patients with moderate or severe depression benefit from initial brief psychological interventions, this could reduce the burden of more intensive treatment on the patient, service providers and commissioners. Stepped care systems need to ensure a smooth transition between steps so that patient experience is not disjointed.

Any local care pathway should describe the way in which patients move through the stepped care process, by whom they are treated and at what point.

In line with the stepped care model, commissioners will wish to ensure that services providing CBT are part of a comprehensive care pathway for patients. However, it is important to recognise that psychotherapies other than CBT - including behaviour therapy, interpersonal therapy, problem-solving therapy, non-directive counselling and short-term psychodynamic psychotherapy - may be appropriate for some patients. ‘Commissioning a brighter future: Improving Access to Psychological Therapies - positive practice guide' describes the key stages that primary care trusts (PCTs) need to consider in order to commission the appropriate range of psychological therapies to meet the common mental health needs of the local community.

Developing a high-quality service providing CBT for the management of common mental health problems

Improving Access to Psychological Therapies outline service specification, produced by the Care Services Improvement Partnership (CSIP) and National Institute of Mental Health in England (NIMHE), describes general service principles and provides a broad framework to enable and encourage opportunities for service innovation of individual commissioners and providers.

Within the NHS, a wide range of health professionals deliver psychological therapies. Most of these practitioners have a primary professional qualification, but the extent of training in psychological therapy in general, and in CBT in particular, varies between the professions, as does the extent to which the practitioners have acquired additional post-qualification training. Commissioners will wish to ensure that therapists are competent to deliver low-intensity and high-intensity CBT to a high standard, and that the service has enough therapists to meet the needs of the local population. The competences required to deliver effective cognitive and behavioural therapy for people with depression and with anxiety disorders identifies the activities associated with the delivery of high-quality cognitive and behavioural therapy and the competences required to achieve these.

Computerised CBT (CCBT) is an alternative to therapist-delivered CBT, and is a generic term used to refer to a number of methods of delivering CBT via an interactive computer interface. It can be delivered on a personal computer, over the Internet or via the telephone using interactive voice response systems. A wide range of health or social care personnel can be used to facilitate the sessions. Improving Access to Psychological Therapies programme (IAPT): computerised cognitive behavioural therapy (CCBT) implementation guidance provides advice and support on how PCTs can provide CCBT to their local communities.

Commissioners may wish to consider CBT for the management of common mental health problems in a number of different ways, and mixed service models of provision may be appropriate across a local health economy. Commissioners may want to consider a range of access routes to services providing CBT, although the majority of referrals will be from primary care, and will need to be confident that appropriate referral and/or self-referral processes are in place to support such access.

The Improving Access to Psychological Therapies Commissioning Toolkit can help PCTs improve or establish stepped care psychological therapies following NICE guidelines. Structured around the commissioning cycle, and linked to the world class commissioning competencies, it brings together a wide range of existing tools and guides and includes positive practice examples throughout. The Improving Access to Psychological Therapies implementation plan: national guidelines for regional delivery provides strategic health authorities, PCTs, training providers and service providers with an overview of what is needed to deliver IAPT, including CBT.

Local stakeholders, including service users and carers, should be involved in determining what level and character of CBT is provided for the management of common mental health problems in order to meet local needs. CBT should be patient-centred and integrated with other elements of care for people/patients with depression, OCD, PTSD and anxiety. As part of this, consideration should be given to ease of access and service location; commissioners should engage with service users and other relevant individuals and organisations locally.

The service specification needs to consider:

• the required competences of, and training for, staff responsible for providing the service
• the expected number of patients (this should take into account how quickly any changes in service provision are likely to take place)
• ease of access and service location; commissioners should engage with service users and other relevant individuals and organisations locally
• care and referral pathways
• information and audit requirements, including IT support and infrastructure
• planned service improvement, including redesign, quality, equitable access, and referral-to-treatment times according to the 18 week patient pathway or equitable waiting times locally for those services currently outside 18 weeks
• service monitoring criteria.

Further useful sources of information may include:

• Delivering the 18 week patient pathway: 18 week commissioning pathways
• The ‘Map of medicine' provides an information resource that visually organises the latest evidence and best practice guidelines
• The NICE ‘shared learning' database offers examples of how organisations have implemented NICE guidance locally
• NICE cost impact report for NICE clinical guideline CG90 on depression
• NICE cost impact report for NICE clinical guideline CG31 on obsessive-compulsive disorder
• NICE implementation advice for NICE clinical guideline CG31 on obsessive-compulsive disorder
• NICE cost impact report for NICE clinical guideline CG26 on post-traumatic stress disorder
• NICE analysis of cost impact for NICE technology appraisal TA97 on computerised cognitive behavioural therapy for anxiety and depression