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’.
