The Lost 40%

I’ve agonized for some time about how best to write this post. I want to try and be objective and sober about our achievements in developing successful interventions for mental health problems, yet at the same time I don’t want to diminish hope for recovery in those people who rely on mental health services to help them overcome their distress.

The place to start is a meta-analysis of cognitive therapy for worry in generalized anxiety disorder (GAD) just published by my colleagues and myself. For those of you that are unfamiliar with GAD, it is one of the most common mental health problems, is characterized by anxiety symptoms and by pathological uncontrollable worrying, and it has a lifetime prevalence rate of between 5-8% in the general adult population. That means that in a UK population of around 62 million, between 3 and 5 million people will experience diagnosable symptoms of GAD in their lifetime. In a US population of 311 million these figures increase to between 15 to 25 million sufferers within their lifetime. Our meta-analysis found that cognitive therapy was indeed significantly more effective at treating pathological worrying in GAD than non-therapy controls, and we also found evidence that cognitive therapy was superior to other treatments that were not cognitive therapy based.

So, all well and good! This evidence suggests that we’ve developed therapeutic interventions that are significantly better than doing nothing and that are marginally better than some other treatments. Our results also suggest that the magnitude of these effects are slightly larger than had been previously found, possibly indicating that newer forms of cognitive therapy were increasingly more effective.

But what can the service user with mental health problems make of these conclusions? On the face it they seem warmly reassuring – we do have treatments that are more effective than doing nothing, and the efficacy of these treatments is increasing over time. But arguably, what the service user wants to know is not “Is treatment X better than treatment Y?”, but “Will I be cured?” The answer to that is not so reassuring. Our study was one of the first to look at recovery data as well as relative efficacy of treatments. Across all of the studies for which we had data on levels of pathological worrying, the primary recovery data revealed that only 57% of sufferers were classed as recovered at 12 months following cognitive therapy – and, remember, cognitive therapy was found to be more effective than other forms of treatment. To put it another way, 43% of people who underwent cognitive therapy for pathological worrying in GAD were still not classed as recovered one year later. Presumably, they were still experiencing distressing symptoms of GAD that were adversely affecting their quality of life. I think these findings raise two important but relatively unrelated issues.

First, is a recovery rate of 57% enough to justify 50 years of developing psychotherapeutic treatments for mental health disorders such as GAD? To be sure, GAD is a very stubborn disorder. Long-term studies of GAD indicate that around 60% of people diagnosed with GAD were still exhibiting significant symptoms of the disorder 12 years later (regardless or not of whether they’d had treatments for these symptoms during this period). Let’s apply this to the prevalence figures I quoted earlier in this piece. This means that the number of people in the UK and the USA suffering long-term symptoms of GAD during their lifetime might be as high as 3 million and 15 million respectively. In 50-years of developing evidence-based talking therapies, have we been too obsessed with relative efficacy and not enough with recovery? Has too much time been spent just ‘tweaking’ existing interventions to make them competitive with other existing interventions? Perhaps as our starting point we should be taking a more universal view of what is required for recovery from disabling mental health problems? That overview will not just include psychological factors it will inevitably include social, environmental and economic factors as well.

Second, what do we tell the service user? Mental health problems such as GAD are distressing and disabling. Hope of recovery is the belief that most service users will take into treatment, but on the basis of the figures presented in this piece, it can only be a 57% hope!  This level of hope is not just reserved for cognitive therapy for GAD or psychotherapies in general, it is a figure that pretty much covers pharmaceutical treatments for GAD as well, with the best remission/recovery rates for drug treatments being around 60% (fluoxetine) and some as low as 26%.

I have spent this post discussing recovery from GAD in detail, but I suspect similar recovery levels and similar arguments are relevant to other forms of intervention (such as exposure therapies) and other common mental health problems (such as depression and anxiety disorders generally). It may be time to start looking at the bigger picture required for recovery from mental health problems so that hope can also be extended to the 40-45% of service users for whom we have yet to openly admit that we cannot provide a ‘cure’.