Of the many public health problems that the NHS grapples with, the increasing burden of poor mental health is inarguably one of the worst. Many studies have shown a deterioration in mental health in England in 2020 and 2021, as heightened anxiety, depression, loneliness and stress coincided with national lockdowns and high Covid-19 case numbers.
While pandemic-induced distress has since eased, it drew attention to the sobering fact that mental health has worsened over time. In England, cases of depression, anxiety and psychosis have increased every year over the last five years, prompting the question: how has the prevalence of mental ill health been felt within the NHS over time?
How have referrals to services changed?
NHS Talking Therapies for Anxiety and Depression, previously known as IAPT (Improving Access to Psychological Therapies), is an NHS delivered service that offers a course of psychological therapy to individuals with depression or anxiety disorders.
Between 2018 and 2022, the total number of referrals and those beginning treatment after referral increased every year apart from 2020, where they plunged sharply during the onset of the Covid-19 pandemic. They recovered by the end of 2020, and in Q2 of 2022/23 (July-September 2022) the total number of referrals were 12% higher than in the same quarter of 2018/19. The total number of individuals beginning treatment after referral grew in lockstep by 12% over the same period as well.
Community mental health services are secondary care services designed for those with severe mental health conditions (inclusive of psychosis, eating disorders, and bipolar mood disorder), enabling them to access specialised care as close to their home as possible.
While 90% of mental health conditions are cared for at primary care level, community services cater to those 10% whose clinical profile requires specialised attention. Apart from a plummet in referrals in 2020 (as already discussed), the total number of referrals per year has increased every year since 2018. In Q1 of 2022/23 (April-June 2022), 1,156,131 referrals were made to community mental health services – a 32% increase since Q1 of 2018/19 when 876,437 referrals were made.
Is psychological treatment meeting people’s needs?
The surge in referrals has been accompanied by a deterioration of service, in terms of access and effectiveness. In Q2 of 2022/23, 34% of newly registered patients waited over a month for their second talking therapy appointment, compared to 29% in the same quarter of 2018/19.
In 2022, 39% of individuals who received talking therapy reported that it helped their mental health to some extent – a smaller proportion than in 2018 when 42% made the same claim. One in three individuals who received specialist treatment for mental health stated that, in 2022, they had not seen someone from NHS mental health services often enough to meet their needs, which compared to one in five in 2018. If these services fail to address people’s needs, it may result in higher reliance on pharmaceutical interventions and emergency services.
How has the use of medication changed?
Medication, in the form of antidepressants, is widely available as a pharmaceutical treatment option for many common mental disorders. Between Q2 of 2018/19 and Q2 of 2022/23, prescription items (the number of times a product appears on a prescription form) written by GPs and dispensed in the community for antidepressants increased by 21%.
It is worth noting that despite the decrease in GP visits during 2020/21, the number of items that year was higher than in 2019/20. What’s more, the academic debate surrounding the effectiveness of SSRIs (an antidepressant that features among the 10 most highly prescribed medicines by NHS primary care services) makes the evidence backing the use of SSRIs appear weaker while their use escalates.
Is access to psychological and pharmaceutical treatment the same?
The increase in talking therapy referrals and antidepressant prescriptions demonstrates a rise in demand for psychological and pharmaceutical treatment for common mental health conditions.
However, the increase in prescriptions (21%) far outweighs the increase in referrals (12%). In 2021/22, 8.3 million individuals received (and were dispensed) antidepressant prescriptions, while 1.8 million were referred to talking therapies – resulting in over four times as many individuals being offered access to pharmaceutical care than NHS psychological care.
This skew in treatment pattern could be because antidepressants serve as long-term treatment after individuals complete a course of talking therapy. It could also be because individuals often seek help when they can no longer cope, making faster channels of care seem more inviting than services where service capacity and stigma are barriers to access.
What can we conclude?
The rise in mental ill health is starkly visible within the NHS. Against a backdrop of increasing referrals for talking therapy and community mental health care, the ability of services to meet people’s needs is diminishing.
There is also an asymmetry in treatment pattern, with more individuals being offered access to pharmaceutical care than psychological care. The NHS aims to increase access to talking therapies, but to do so in an effective manner for patients requires understanding their experiences better. Not only will this create a more responsive service, but also a mentally healthier population.
Bagri S (2023) “NHS mental health services: what’s changed?" QualityWatch: Nuffield Trust and Health Foundation.