In an interview with Joel Suss, editor of the British Politics and Policy blog, Richard Layard discusses the importance of combating mental illness and his new book, Thrive: The Power of Evidence-Based Psychological Therapies, which he co-authored with David Clark. Both authors presented the findings and arguments of their new book at a public event at the LSE with Andrew Marr.
In Thrive you show that 1 out of every 6 adults in Britain suffers from a mental health disorder, yet only 1 in 3 people suffering will receive treatment. You have called this “one of the great injustices of our time”. How did we get to this situation?
The fundamental reason is that until recent decades there really weren’t any treatments for depression or anxiety disorders which could be shown to make a difference. The first advances were in drug treatments but these had quite small effects on the danger of relapse. The biggest and most important advance has been in psychological treatments, both because they have much longer lasting effects and because they’re what most patients want. One reason for the under-treatment was that people just didn’t want to take the drugs with the side effects they entailed. What they wanted was to be helped to get control over their own mental life, and that’s what the psychological therapies enable people to do.
That said, it’s some time since these therapies became pretty well established and the shocking thing was that up to 2008 these evidence-based therapies, in particular cognitive behavioural therapy but also interpersonal therapy and other therapies, which are recommended by Britain’s standards agency called NICE [National Institute for Health and Care Excellence], were meant to be provided by law according to the statutes of the NHS. But the guidelines for mental illness and particularly depression anxiety disorders were being completely disregarded by the National Health Service.
Why is that?
It could possibly be a degree of ignorance, but it is surely more down to a lack of pressure from the families of people suffering from these conditions as compared with physical conditions – like heart problems, cancer and so on – where there is intense pressure, not only of course from the families, but the drug companies. The problem with psychological therapies is that there’s nobody making money out of it and therefore the lobbying is of a completely different order from the lobbying in favour of the acute sector. An additional problem in the NHS now is that we’ve got payments per unit of service for physical illness and block contracts for mental illness. Therefore the money gets eaten up every time somebody goes for a physical treatment. The only way the commissioners can think of surviving is to clamp down on mental health treatments. That this system should have been allowed to persist is a complete scandal, but it’s a sort of proximate explanation of the behaviour of commissioners. We have to change the behaviour of the commissioners.
Starting from 2008 – when almost nobody was getting evidence-based psychological therapy for depression or anxiety disorders – a completely new service was established called Improving Access to Psychological Therapy (IAPT), which was to build up steadily, year-by-year. It involves a training programme aimed at training 1,000 or more therapists every year in a wave of services that were accredited year after year so that, instead of trying fruitlessly to raise the standards across the board, they were raised systematically in a feasible way. This has been pretty much achieved. Of course, there are many things which are not as one would have hoped that they would be, as in any system, but we now have trained up to 6,000 therapists and have services in most parts of the country. They’re still not seeing enough people at all, and in particular they’re not seeing the huge number, something like 4 million people in Britain, who are co-morbid; who have physical illness problems accompanied by mental health problems. It’s extraordinarily important that those get help with their mental health conditions. This also helps their physical health. It needs a more sophisticated form of psychological treatment than the sort of standard psychological treatment for depression and anxiety disorders not accompanied by physical treatment. That’s a huge challenge. The main, hidden objective of our book is to persuade all the political parties in their election manifestos to commit to doubling the size of the IAPT programme in terms of number of people seen by 2020, and I really hope that it will have that effect.
What evidence led you to these conclusions? What impact does untreated mental illness have on the economy and on society?
Depression and anxiety disorders are enormously costly to the economy. If you take all mental health disorders this is costing something like 8 per cent of our national income. Half of that is due to the fact that roughly half of all the disabled people in the country are disabled by mental health problems. Most of these people are not working and are receiving benefits. There’s also a big impact on crime coming from mental illness, and that’s on the cost of law enforcement, criminal justice and so on. Then there’s the cost to the health service itself, which includes the cost of the additional physical health care which mental ill people get for any given condition, any given physical illness. Somebody who’s mentally ill costs the NHS £2,000 a year extra in terms of their use of physical health care facilities – accidents, emergencies, hospital admissions, hospital consultations, procedures and so on. There’s a huge amount that could be saved to the physical health care system by a wider availability of psychological therapy and that is the campaigning point which we are trying to make most strongly.
Of course there are other savings to the public as well because of the huge burden of welfare benefits coming from people who are disabled because of mental illness. The cost of treating psychological therapy is, if you take all conditions from the mildest to the most severe, a one-off cost of £650. The cost to the treasury of having somebody on disability benefits because of mental illness is £650 every single month, month after month after month. Now of course a service is going to treat all comers, and only some of them will be on those benefits. But again if you work through the calculations you can see that enough people would be coming off those benefits or not going on to them for the savings on benefits and lost taxes. This would again to pay for the service, so our case is that the IAPT is a service, which if expanded, would cost nothing because it would pay for itself twice over – once in savings in healthcare benefits and the second time in the savings in healthcare benefits and taxes. It is a complete no-brainer. That’s why we’re really hoping that the political parties will grab it and go for it in their election manifestos, in particular the doubling of access to the IAPT programme by 2020.
You also argue in the book that mental ill-health causes more suffering than physical ill-health.
Yes, I think it is a sad reflection on our priorities that we have to make such a song and dance about this costing nothing. When we’re treating cancer or heart disease we don’t have to argue that it costs nothing. The fact is that the suffering caused by mental illness is at least as great as the suffering caused by physical illness in our society. If you look, and you can do this of course with the kinds of population surveys we have like Understanding Society in Britain, which is a very good survey of over 100,000 people, you can identify those people who are the most miserable and then you can find out what distinguishes them from the rest of the population. You will find that mental illness is the biggest single cause of misery in our society, bigger than physical illness and very much bigger than poverty or unemployment. I spent most of my life working on how to reduce poverty and unemployment; they are genuine problems but are fortunately more in people’s minds than mental illness. We really have to get a different priority for mental illness. We had a rather famous director of the LSE called William Beveridge who produced his famous report shortly after leaving the LSE in which he pointed to the five giants that were the problems to be addressed; education, income, employment, housing and physical health. We’re arguing that we need to have a sixth giant in everybody’s minds, and that’s mental health. There should be a separate cabinet minister for it as there is for all the others.
You are known as the ‘happiness tsar’ for your work on happiness economics and a book you’ve written entitled Happiness. How does you argument in Thrive relate to your pursuit to put happiness at the centre of public policy?
If you’re thinking about what we could we do to improve the happiness of the population, probably the most obvious thing that we could do would be to do something directly for people who are currently mentally ill, and that’s why we have been giving such priority to the IAPT programme. I’ve been hugely influenced by my co-author David Clark, one of the world’s leading clinical psychologists. He always stressed to me that the aim of therapy is not to help people manage their condition but to recover and be free of it. This is a very important and different way of thinking which these therapies have brought to the situation. If you had a million pounds or dollars, where would be the most compelling case for spending them? If there are people in front of you who are suffering and there are treatments which would relieve their suffering and they’re not getting them, that seems to me an absolutely overwhelming case for the spending of money.
Of course we would like people not to get into this condition in the first place, so there is also the huge public health issue of promoting good mental health and preventing bad mental health which in particular takes you into schools. I think we have to have a very different philosophy of education in which schools are trying to help develop the character of children as much as their competence, and there are evident ways of doing that which are being developed and will have to be further developed. There are many ways in which our society could be improved which would lead to lower levels of mental illness. Less of this excessive emphasis on competition between people and more on cooperation, and so on. Some old causes are very relevant to the mental health question, as to other dimensions of human wellbeing.
So I do see this as a part of the happiness programme. I was lucky enough to be, incidentally, a member of a group chaired by Gus O’Donnell that produced a very important report, called Wellbeing in Policy, about how government could optimise the wellbeing of the population rather than whatever it is at the moment. All the members of that group were unanimous on the importance of raising the priority attached to mental health. Educational priorities is another big area, more support for parents another big area, and, in a general sort of way, an understanding that the wellbeing of the population does not just depend on their material standards as too many politicians assume. Just as at one time it was considered extraordinary for the state to become involved in education, we’ve got to expect the state to become involved in helping people gain control of their lives, their internal-lives. It’s been the neglect of the person within that accounts for the very depressing fact that, for the United States in particular, there’s been no increase in happiness in the last 60 years despite huge increases in wealth. It is mainly because we haven’t paid enough attention to the inner life and the way in which society as a whole can support people in developing satisfying inner-lives as well as external-lives.
Are you optimistic that this situation can change and mental illness will become a greater priority?
I am quite optimistic. There are people in every party who are very much onside for this. I would think the political class is actually more on side for this than the NHS. So there are two tasks: the first is to persuade the politicians to put it in the manifesto. The second is to make sure that once it’s in the manifesto it happens on the ground. To this end we are producing proper public information about how different services in different parts of the country are doing, and local groups can put pressure on their local commissioners and local providers to step up to the mark.
Richard Layard, along with his co-author David Clark, spoke at an LSE public event chaired by Andrew Marr.
Note: This article gives the views of the interviewee, and not the position of the British Politics and Policy blog, nor of the London School of Economics. Please read our comments policy before posting.
Richard Layard is Emeritus Professor at the London School of Economics, programme director of the Centre for Economic Performance, and a Labour life peer in the House of Lords. He is a labour economist who has worked for most of his life on how to reduce unemployment and inequality. He is also one of the first economists to have worked on happiness, and his main current interest is in how better mental health could improve our social and economic life. He is the author of many books, including Happiness: Lessons from a New Science and Thrive: The Power of Evidence-Based Psychological Therapies, his latest book co-authored with David Clark.