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Equity of access to psychological therapies

  • David A. Richards (a1) and Peter Bower (a2)
Summary

Improving access to psychological treatments for common mental disorders is a priority in a number of countries worldwide. We consider the evidence presented by Harris et al on the Australian Better Access initiative, and discuss the challenges of delivering such intitiatives and evaluating their impact.

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Copyright
Corresponding author
David Richards, Mood Disorders Centre, Washington Singer Building, School of Psychology, University of Exeter, Exeter EX4 4QG, UK. Email: d.a.richards@exeter.ac.uk
Footnotes
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See pp. 99–108, this issue.

Declaration of interest

D.A.R. is a paid clinical informatics advisor to the Improving Access to Psychological Therapies Programme at the UK Department of Health. P.B. is a paid scientific consultant to the British Association of Counselling and Psychotherapy.

Footnotes
References
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1 Campbell, S, Roland, M, Buetow, S. Defining quality of care. Soc Sci Med 2000; 51: 1611–25.
2 Harris, MG, Burgess, PM, Pirkis, JE, Slade, TN, Whiteford, HA. Policy initiative to improve access to psychological services for people with affective and anxiety disorders: population-level analysis. Br J Psychiatry 2011; 198: 99108.
3 Clark, D, Layard, R, Smithies, R, Richards, D, Suckling, R, Wright, B. Improving access to psychological therapy: Initial evaluation of two UK demonstration sites. Behav Res Ther 2009; 4: 910–20.
4 Bower, P, Gilbody, S. Managing common mental health disorders in primary care: conceptual models and evidence base. BMJ 2005; 330: 839–42.
5 McManus, S, Melzer, H, Brugha, P, Bebbington, P, Jenkins, R. Adult Psychiatric Morbidity in England, 2007: Results of a Household Survey. NHS Health and Social Care Information Centre, 2009 (http://www.ic.nhs.uk/pubs/psychiatricmorbidity07).
6 Glover, G, Webb, M, Evison, F. Improving Access to Psychological Therapies: A Review of the Progress made by Sites in the First Roll-out Year. The North East Public Health Observatory, 2010.
7 Richards, D, Weaver, A, Utley, M, Bower, P, Cape, J, Gallivan, S, et al. Developing Evidence Based and Acceptable Stepped Care Systems in Mental Health Care: An Operational Research Project (Final Report). NIHR Service Delivery and Organisation programme, 2010.
8 Waller, R, Gilbody, S. Barriers to the uptake of computerized cognitive behavioural therapy: a systematic review of the quantitative and qualitative evidence. Psychol Med 2010; 39: 705–12.
9 Summerfield, D, Veale, D. In Debate: proposals for massive expansion of psychological therapies would be counterproductive across society. Br J Psychiatry 2008; 192: 326–30.
10 Dixon-Woods, M, Kirk, D, Agarwal, S, Annandale, E, Arthur, T, Harvey, J, et al. Vulnerable Groups and Access to Health Care: A Critical Interpretive Synthesis. NIHR Service Delivery and Organisation programme, 2005.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Equity of access to psychological therapies

  • David A. Richards (a1) and Peter Bower (a2)
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eLetters

A tale of two studies: Separate evaluations of Better Access yield similar findings

Meredith G. Harris, Senior Research Fellow
12 April 2011

Richards and Bower (1) discuss challenges in evaluating programs designed to meet population need for mental health treatment by improving access to psychological therapies, such as the UK’s Improving Access to Psychological Therapies initiative and Australia’s Better Access initiative. In Australia, there has been considerable debate about the merits of Better Access, much of which has focused on concerns that it is not reaching traditionally underserved groups (2,3). Until recently, this debate has been limited by reliance on Medicare (Australia’s universal health insurance system) claims data which include only basic socio-demographic measures and no measures of mental health need.

Two recent studies (4,5) have examined access and equity questions inrelation to Better Access using datasets that include individual-level Better Access service use and mental health need measures. Neither datasetwas designed for the purpose of evaluating Better Access. Although the studies differed in their methodologies, they yielded similar results.

Byles et al (4) linked Australian Longitudinal Study on Women’s Health (ALSWH) data and Medicare records for 14,911 women aged 36-41, 63-68 and 88-93 (younger, mid-age and older cohorts) in 2007. Harris et al (5) used cross-sectional data from the National Survey of Mental Health and Wellbeing (NSMHWB), a nationally representative household survey of 8,841 Australian women and men aged 16-85 in 2007. Byles et al could accurately identify use of items via Medicare records; Harris et al reliedon respondents reporting Medicare-reimbursed visits to allied health providers. Harris et al could accurately determine respondents’ diagnoses because the NSMHWB included a structured diagnostic instrument; the ALSWH relied on self-report of a relevant doctor’s diagnosis (plus SF-36 Mental Health Index scores).

Both studies reported similar uptake. Restricting their respective analyses to individuals with anxiety/depression, Byles et al found 12% and10% of the ALSWH younger and mid-aged cohorts had made relevant Medicare claims for allied health and GP services, and Harris et al found 8% of NSMHWB respondents had made Medicare claims for allied health services. Both reported uptake for 2007, potentially underestimating current uptake by 100%.

Both studies found Better Access reached “new” consumers. Byles et alfound 93% of women who used Better Access items had not previously seen a counsellor, psychologist or social worker. Harris et al found 62% of people with current depression/anxiety who used Better Access allied health items had not previously seen these providers.

Both studies showed that clinical need predicted Better Access use. In longitudinal analyses, Byles et al showed women who used the Better Access items tended to have poorer and/or recently declining mental health. Harris et al found that greater severity of disorder and presence of depressive disorder predicted use of the allied health items.

Findings regarding potentially disadvantaged groups were partially consistent. Neither study found differences in uptake due to country of birth or residential area. Byles et al reported lower uptake among women struggling financially and/or lacking post-school qualifications. Harris found that uptake was lower among people with anxiety disorders (without comorbid depression), but that relative socio-economic disadvantage, household income, education, and employment did not predict use after controlling for clinical factors. Variation in results may relate to differences in sampling, measures and analysis. Byles et al considered women only, deemed all Better Access item users to have a mental disorder,and tested each socio-economic factor in univariate analyses; Harris et alincluded men and women, limited analysis to people with current disorders,and conducted a multivariate analysis.

We agree with Richards and Bower that studies investigating access and equity are essential, although not sufficient, components of a comprehensive evaluation strategy for such initiatives. We add that the examination of datasets measuring mental health need as well as service utilisation is required to build the evidence base on which to judge whether Better Access is equitably meeting population need.

Declaration of interest: The Byles et al study was funded by a grant from Australian Rotary Health. The ALSWH and NSMHWB are funded by the Department of Health and Ageing. Meredith Harris and Jane Pirkis have received funding from the Department of Health and Ageing to undertake work related to a separate evaluation of Better Access.

References:

1. Richards DA, Bower P. Equity of access to psychological therapies (editorial). Br J Psychiatry 2011; 198: 91-92.

2. Hickie IB, McGorry PD. Increased access to evidence-based primary mental health care: will the implementation match the rhetoric? MJA 2007; 187: 101-103.

3. Rosenberg S, Hickie IB, Mendoza J. National mental health reform: less talk, more action. MJA 2009; 190:193-195.

4. Byles JE, Dolja-Gore, Loxton DJ, Parkinson L, Stewart Williams JA.Women’s uptake of Medicare Benefits Schedule mental health items for general practitioners, psychologists and other allied mental health professionals. MJA 2011; 194: 175-179.

5. Harris MG, Burgess PM, Pirkis JE, Slade TN, Whiteford HA. Nationalpolicy initiative to improve access to psychological services for people with affective and anxiety disorders: A population-level analysis. Br J Psychiatry 2011; 198: 99-108.
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Conflict of interest: None Declared

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