British care for the mentally ill - a model for Germany?

State aid for the health system: Great Britain launched an unusual project in 2007. The "Improving Access to Psychological Therapies" (IAPT) initiative aims to save public costs in the long term by improving the care of the mentally ill. With the help of IAPT, patients with mental disorders should receive evidence-based psychotherapy within just a few weeks. Several thousand psychotherapists are to be newly trained for this purpose. The British Ministry of Health is investing at least 300 million British pounds.

>> In October 2007, the British Ministry of Health announced that it would provide at least 300 million British pounds (the equivalent of approx. 345 million euros) in special funds for a special kind of health project: Access to evidence-based psychotherapy should be improved quickly and efficiently. The goals of this unprecedented project are ambitious. In the next three years alone, almost a million patients (900,000 to be exact) are expected to receive psychotherapy in addition to the current ones. In order to carry out these therapies, a further 3,600 psychological therapists will initially be newly trained. In the longer term, there are plans to train a total of 8,000 new psychotherapists. The waiting time for such a place in psychotherapy is to be reduced from the current eighteen months to just a few weeks.
The main motive for this major project is of course economic: the British government has recognized that rapid and effective psychotherapy can save significant costs for the national budget in the long term. What led the UK Department of Health to this rethink and such a large investment? Subsequent developments are believed to have contributed significantly to the support of the IAPT initiative.
Preliminary developments of the IAPT initiative in Great Britain

The work of the National Institute for Health and Clinical Excellence (NICE), founded in 1999, is of central importance. This institute can be roughly compared with the Institute for Quality and Efficiency in Health Care (IQWiG), which was founded in Germany in 2004. The British NICE aims to provide comprehensive, evidence-based advice on physical and mental health. The tasks of NICE are diverse: Among other things, over 80 clinical guidelines have been created for the evidence-based treatment of medical and psychological problems. Comprehensive recommendations for therapy can also be found for all common mental disorders.
“Mental health is Britain's biggest social problem.” This and similar clear statements come from Professor Sir Richard Layard, an English economist. Under his leadership, the “Depression Report” was published in 2006, which points out deficiencies in the care of mentally ill people and predicts high cost savings through psychotherapy. According to Layard and colleagues, in the UK more people with mental disorders receive financial benefits than people who are unemployed. Forty percent of periods of incapacity to work are due to psychological disorders. One in six people suffer from depression or chronic anxiety. However, only one in four people receive any treatment for their mental disorder. When treated, medication is usually used. These care data are countered by new possibilities: “The good news is that we now have evidence-based psychological therapies that can lift at least half of those affected out of their depression or their chronic anxiety. These new therapies are not endless nor backward-looking treatments. They are short, forward-looking treatments that enable people to challenge their negative thinking and build on the positive side of their personalities and situations.” (Depression Report, p. 1). According to work by NICE, these therapies are just as successful as pharmacotherapy (see Depression Report, p. 1). In addition, they are actually preferred by the majority of patients (Chilvers et al., 2001). According to Layard et al., the costs of psychotherapy were similar. entirely with the savings from fewer disability payments and higher tax revenue.
This health report was followed by the first preliminary phase of the IAPT program. In 2006, 5,500 new patients were allocated to two model sites (Doncaster and Newham). Of these, 1,900 patients received a short cognitive-behavioral treatment program (average number of sessions: Doncaster: 4.9; Newham: 8.2). Fifty-two percent of patients with anxiety or depressive disorders that had existed for more than 6 months were completely improved after therapy. In follow-up assessments conducted an average of 42 weeks after the last session, over 40 % (Doncaster: 40 %, Newham: 43 %) were considered to be completely and stable improved. Additional findings emerged due to the facilitation of access to a psychotherapist through self-referral: Unlike in Germany, in Great Britain, referral to a psychotherapist is currently only possible via the family doctor. The data show that patients who sought psychotherapeutic help directly were similarly impaired to those who were referred by doctors. These two groups also did not differ in terms of treatment success. However, the mental disorders in those who came on their own initiative had already existed for twice as long as in the patients referred by a doctor. This suggests that the self-referral option can also provide help to people who were previously reluctant to consult an organ health specialist. The final report on the preliminary study in Doncaster and Newham, published in October 2008, can be viewed online (see http://www.iapt.nhs.uk/wp-content/uploads/2008/10/lse_report.pdf (accessed on May 18th). 2009)).
This is the situation in Great Britain. The following documents the extent to which the findings from IAPT, NICE and Depression Report can be generalized for Great Britain or are particularly valid for Germany. Taking into account the current state of scientific knowledge, the following questions arise:
• Is the British supply situation for psychotherapy comparable to that in Germany?
• Can psychotherapy actually save public costs?
• How does psychotherapy compare to pharmacotherapy in terms of benefits and costs?

Finally, some desirable perspectives for Germany are formulated.
Care situation for outpatients
Psychotherapy in Germany
At first glance, things are better regulated in Germany. This year the Psychotherapists Act is celebrating its 10th birthday. Since it came into force on January 1st, 1999, anyone can consult a psychotherapist directly without having to be referred by a doctor, as was previously the case. As the UK data shows, facilitating initial contact can prevent chronicity. Thanks to the Psychotherapist Act, someone who visits a psychotherapist can also trust that the psychotherapist has a state-regulated qualification. Nowadays, only people who have completed high-quality additional training of at least three years are allowed to call themselves “psychotherapists”. Results of a representative survey show that the reputation of psychotherapy has increased significantly over the 11-year period (Angermeyer & Matschinger, 2005).
But if you take a closer look at the supply data for psychotherapy, there are also grievances in Germany. Psychotherapy for mental disorders is by no means the first priority when it comes to use. According to a representative survey by Rief et al. (2005), only 16 % of patients with depressive disorders and 17 % of patients with panic disorder were seen by a psychotherapist. In other words: over 80 % of the people with mental disorders did not receive any psychotherapy, but were, if at all, treated with organ medicine-oriented general practitioners or specialists. A somewhat older representative study by Margraf & Poldrack (2001) provides even more drastic figures. Only 42 % of those suffering from anxiety disorders were treated at all, mostly through pharmacotherapy or non-specialists. Psychotherapy was only used for a total of 8 % respondents. Cognitive behavioral therapy as the procedure with the best evidence of effectiveness for anxiety disorders (e.g. Ruhmland & Margraf, 2001) was identified as such in only 1 % of the anxiety patients in the interviews. It is expected that, to date, a significant number of people with mental disorders are still not receiving evidence-based treatment.
The reasons for the rare use of psychotherapy are probably diverse. In a population-representative survey (Zepf et al., 2003), only half of those who requested therapy received an appointment. The respondents waited an average of two months for a preliminary interview and five months for a treatment place. For a worryingly high percentage (39 %) no psychotherapy subject to authorization was applied for after the probatory sessions (first 5 sessions). Many people with mental illnesses requiring treatment were not admitted despite indications from psychotherapists. A secondary result of the study was that patients with disorders from the psychosomatic area remained untreated significantly more frequently, although certain psychotherapy procedures are considered the method of first choice for some of these disorders (Weise et al., 2007; Nestoriuc et al., 2008).
Of course, the situation in Great Britain is dire at the moment. However, if you imagine the consequences that the waiting time in Germany has for those affected and those around them, the situation in Germany does not seem tenable either: A patient with panic attacks can only leave the house if she is accompanied by family members. A patient becomes unable to work due to depression and becomes increasingly socially withdrawn. An anorexic young woman continually loses weight and the condition becomes life-threatening. In all cases, it seems ethically questionable to make these people wait for almost half a year. In addition, waiting times lead to an additional economic burden. Progressive mental disorders without adequate treatment lead to inability to work and hospitalizations. Both are accompanied by costs borne by society as a whole that far exceed the costs for outpatient psychotherapy.
Evaluation of the cost-benefit ratio
for psychotherapy
Around one in three adult Germans suffers from a mental disorder (Wittchen & Jacobi, 2001). Mentally ill people incur a high level of public costs. It can be assumed that the indirect costs due to periods of incapacity to work and pensions account for the largest share, but the direct costs due to expenses for treatments (e.g. medication, psychotherapy, inpatient rehabilitation) are also significant. In Germany, depending on the statistics and year, mental disorders rank second to fourth in early retirement and periods of incapacity for work. The proportion of work absences due to mental illnesses is continually increasing. According to WHO calculations, mental disorders account for 20 % of the total burden caused by illness across Europe (WHO, 2001). Trend calculations predict a significant increase in burdens by 2020.
The fundamental benefits of psychotherapy should no longer have to be questioned today. Extensive literature reviews such as those by Grawe et al. (1994) and Lambert & Ogles (2004) put together a broad base of studies that demonstrate a significant improvement in symptoms for almost all mental disorders in an average of around 75 patients. Nevertheless, the “Report 2007” from the Gmünder substitute fund recently caused a stir, from the evaluation of insurance data it was concluded that outpatient psychotherapy had no clearly demonstrable positive effects. This interpretation was based on the fact that two years after applying for psychotherapy, more medical services were used than by the comparison group of insured persons without psychotherapy. There is a lot to criticize about the methodology. In fact, the figures in the GEK report show a significant decrease in doctor contacts among psychotherapy patients after deducting psychotherapy contacts and the quarterly doctor visits necessary for psychotherapy referrals.
In a recently published review, Margraf (2008) presents the current status of empirical cost-benefit analyzes for psychotherapy. A total of 54 studies on 13,000 patients were included in the evaluation. Almost all studies (95 %) showed a reduction in healthcare costs after psychotherapy. After deducting the costs of psychotherapy, 86 % studies had a positive cost-benefit ratio. In most cases, the costs were recouped through savings in the first two years after psychotherapy. Even if psychotherapy becomes 50% more expensive in the future, it is still profitable, as calculations from a therapy study show (Lam et al., 2003).
Comprehensive calculations of cost savings for Germany can be found in Hiller et al. (2003). Health insurance data were collected in the 2-year period before and after inpatient, behavioral therapy treatment of patients with chronic physical complaints that cannot be explained by organ medicine. There was a reduction in healthcare costs of more than 8,000 euros per patient (inpatient treatments: - 1,098 euros / -37 %, outpatient treatments: - 382 euros / -25 %, calculated costs due to fewer periods of incapacity for work: 6,702 euros / -35 %) .
Comparison of psychotherapy and pharmacotherapy
in terms of benefits and costs
It applies equally to Great Britain and Germany that mental disorders are initially treated with psychotropic drugs in most cases (see above). For some patients, this may be the best way to change psychological symptoms. But this is probably not always the case. Studies in recent years on the two most common groups of mental disorders (depression and anxiety) suggest that psychotherapy shows at least comparable success:
• In therapy comparison studies for depressive disorders, comparable effectiveness of medication and psychotherapy is usually found. However, this often only applies as long as the intake of the drug is continued. When antidepressants are stopped, relapses occur more frequently than after the end of psychotherapy (e.g. Hollon et al., 2005).
• For the group of anxiety disorders, results of a Cochrane review (Furukawa et al., 2007) show that psychotherapy for panic disorder is similarly effective in the long term as a combination of pharmaceutical and psychotherapy. However, purely medicinal treatment has less success. Similar results can also be found for other common anxiety disorders, e.g. B. social phobia (e.g. Liebowitz et al. 1999).
In summary, it can be stated that the effectiveness of evidence-based psychotherapy for anxiety disorders is higher and for depression it is at least comparable to modern pharmacotherapy. Nevertheless, pharmacotherapy is offered and used by significantly more patients.
Recent studies also contain cost comparisons of pharmaceutical and psychotherapy. The cost-benefit report by Margraf (2008) described above compiles a total of 17 studies comparing the costs of pharmaceutical vs. psychotherapeutic treatments. Most of these studies (76 %) document lower costs for psychotherapy, in some cases (18 %) drug therapy proved to be cheaper. A study of anxiety disorders documented almost half the cost of pharmacotherapy for individual psychotherapy and only a quarter for group psychotherapy (Otto et al., 2000). Evidence-based psychotherapy appears to be not only partially more effective, but also more cost-effective than drug therapy.
Perspectives for Germany
Even if further cost-benefit studies are indicated, the level of evidence for psychological psychotherapies is far higher than that for many standard medical treatments that have been used for a long time (see Dintsios et al., 2009 in the previous issue in Monitor Healthcare Research 02/09). Nevertheless, evidence-based psychotherapy is still used far too rarely. Long waiting times for outpatient therapy places are seen as one of the reasons for this.
Should the German healthcare system, based on the British model, be given a financial injection of several hundred million euros? A change in the care situation for psychotherapy seems at least urgently indicated.
A point that is sometimes emotionally discussed in Germany is the fact that the psychotherapy carried out in practice in very few cases corresponds to what has been proven to be effective in scientific studies. This applies primarily to the duration of psychotherapy. In international studies, very short therapy procedures of 5-15 sessions often perform particularly well. Comprehensive analyzes (Howard et al., 1986, 1999; Lutz, 2003; Lutz et al., 2001) of non-manualized treatments in care show that across different forms of therapy, patient groups and outcome criteria, the greatest treatment successes occur in the first 30 sessions can be achieved. However, after the 60th therapy session, on average there is no longer any significant gain.
Clinical practice looks different. In Germany, just a few years ago, the average number of outpatient therapy sessions was 70 treatment hours (Löcherbach et al., 1999, see summary in Rief et al., 2006). However, faster therapies enable more therapy places for a fixed period of time. This would be an opportunity to counteract the long waiting times and high rejection rates that have been the norm up to now.
Even in the context of behavioral therapy, which on average has the shortest duration of therapy and can in principle be based on a good scientific foundation, the procedures that are most effective are often not used. Very few behavioral therapists use stimulus exposure (Margraf & Poldrack, 2001; see above), even though this is the method of choice that has been widely proven for anxiety disorders. The aim of such exposure to stimuli is (after extensive preparation of the patient) to confront the anxiety-provoking situations and to remain in them for a longer period of time until a significant reduction in anxiety has occurred (precise descriptions of treatment rationale and implementation can be found in Rief et al., 2006). In order to carry out exposures in typical situations (department stores, towers, bridges or public transport), psychotherapists incur a considerable additional time burden for planning, organization and travel, which remains uncompensated. When carried out lege artis, it is not even clear in advance how long an exposure exercise will last, because the criterion for its completion is the patient's significant reduction in anxiety, which can occur after 20 minutes or even 4 hours. This adds planning uncertainty and loss of earnings. Given this situation, it is unfortunately not surprising that many psychotherapists shy away from using the exposure procedure and that it is so rarely used despite its high effectiveness.
The other regulations that the Associations of Statutory Health Insurance Physicians specify for billing also contribute to this problem situation. In order to approve treatment, a report must usually be drawn up about the patient, justifying the indication and treatment plan for psychotherapy. If the approved quota is not used up and a new therapy is applied for instead, there will be additional work for the practitioner.
In this way, improvements could be achieved in Germany even without major investments. Unfortunately, no psychotherapist is currently rewarded for providing cost-effective, time-condensed, highly efficient treatments. There is no incentive system for the implementation of scientifically based short-term therapies.
Overall, the situation in Germany is not much different than in Great Britain: an unsatisfactorily small proportion of people in need of treatment benefit from evidence-based outpatient psychotherapy. While people in Germany may have sometimes looked at the British health system with a little scorn, if the IAPT project is successful, mentally ill people will look at the British Isles with envy in a few years. Anyone who saves on the mentally ill in the health system is thinking short-term and saving in the wrong place. Adequate treatment is absolutely necessary not only for economic reasons, but also for economic reasons. A lot still needs to change in Germany. <<