A Q&A with Richard Layard and David Clark, authors of THRIVE

Thrive jacketHow can mental illness—an affliction that affects at least 20 percent of people in developed countries, reduces life expectancy, and wrecks havoc on educational potential—remain chronically under-treated? The answer is simple: mental and physical pain are not viewed equally, and even in a relatively progressive culture, the former remains profoundly stigmatized. As a result, most who suffer from mental health issues suffer in silence, or receive inadequate support. Can this change? Richard Layard and David Clark say it can.

In Thrive, Layard and Clark look at the practical politics of increasing access to mental health care, arguing that the therapies that exist—and work—are available at little to no cost. Recently, both took the time to answer some questions about the book, and the transformative power of mental health care.

What is the message of your book?

Depression and anxiety disorders are the biggest single cause of misery in Western societies. They also cause enormous damage to the economy. But they are curable, in most cases, by modern evidence-based psychological therapy. The shocking thing is that very few of those who need it get any help and fewer still get help based on evidence. In England such help is now becoming available to many of millions who need it. As we show, this help involves no net cost to society. It’s a no-brainer.

What is the scale of the problem?

Surveys of households in rich countries show that around 1 in 6 adults have depression or anxiety disorders severe enough to cause major distress and impair the person’s functioning. Only a quarter of these people are in any form of treatment, most usually medication. This is shocking. For surveys show that mental illness is the biggest single reason why people feel dissatisfied with their lives – accounting for more of the misery in our societies than either poverty or unemployment do.

What is its economic cost?

Mental illness accounts for nearly a half of all absenteeism from work and for nearly a half of all those who do not work because of disability. This imposes huge costs on employers and taxpayers. Mental illness also increases the use of physical healthcare. People with a given physical illness of a given severity use 50% more physical healthcare if they are also mentally ill. This is a huge cost to those who fund healthcare.

Does psychological therapy help?

In the last 40 years considerable progress has been made in developing effective psychological therapies. The most studied therapy is CBT – cognitive behavioural therapy, which is a broad heading for therapies which focus on directly influencing thoughts and behaviours – in order to affect the quality of human experience. In hundreds of randomised controlled trials CBT has been shown to produce recovery rates of over 50% for depression and anxiety disorders. For anxiety, recovery is generally sustained; for depression, the risk of relapse is greatly reduced.

The range of therapies which have been shown to work has been surveyed internationally by the Cochrane Collaboration and in England by the National Institute for Health and Care Excellence (NICE). Besides CBT, NICE also recommend for all depressions Interpersonal Therapy (IPT) and, for mild to moderate depression, Brief Psychodynamic Therapy, Couples Therapy and Counselling. Modern psychological therapies have also been shown to be effective in a wide range of other mental health conditions.

Do these therapies really cost nothing?

Yes. If delivered to a representative group of patients they pay for themselves twice over. First, they pay in reduced invalidity benefits and lost taxes due to invalidity. We know this from a series of controlled trials. Second, they pay for themselves in reduced costs of physical healthcare. Again we know this from controlled trials. It is so partly because the typical cost of an evidence-based course of treatment is only about $2,000.

How can these therapies become more widely available?

Two things are needed. First, there have to be enough people trained to deliver these therapies. This is the responsibility of universities and colleges, including of course supervised on-the-job training. Second, there have to be effective frameworks where trained people can be employed. The evidence is that recovery rates are higher where people are employed in teams where they can get supervision, in-service training, and clear career progression.

Those who fund healthcare have in the USA and UK the legal obligation to provide parity of esteem for mental and physical healthcare, and this requires that they are willing to fund high quality evidence-based therapies that are made easily available and provide the necessary duration of treatment, based on evidence. Insurers never fund half a hip replacement and they should not fund only half a proper course of psychological therapy.

What can be learnt from the English experience?

The English National Health Service has in recent years developed a totally new service to deliver evidence-based psychological therapies. (It’s called Improving Access to Psychological Therapies (IAPT)). This service has, over six years, trained altogether 6,000 therapists and is now treating nearly half a million people a year, with a recovery rate of 46% and rising. The prestigious journal Nature has called it “world-beating”.

How can we prevent mental illness in the first place?

First we must of course treat it as soon as it appears. This is often in childhood, where the same evidence-based treatments for depression and anxiety disorders apply as in adulthood. For children’s behaviour problems, parent training and family therapy are recommended.

But we must also reduce the overall prevalence of mental illness. This requires major changes throughout society. First, more support and education for parents. Second, schools which give more priority to the well-being of children. Third, employers who treat their workers with appreciation and encouragement and not as income-maximising machines. Fourth, more positively-oriented media. And finally, a new citizens’ culture giving more priority to compassion, both as an emotion and as a spring for action.

Richard Layard is one of the world’s leading labor economists and a member of the House of Lords.  David M. Clark is professor of psychology at the University of Oxford. Layard and Clark were the main drivers behind the UK’s Improving Access to Psychological Therapies program.

Read chapter one here.