
When launched back in 2008, the Improving Access to Psychological Therapies (IAPT) programme remit was to address the burgeoning social and economic burden of common mental health problems in the UK. From the outset IAPT was aimed at offering evidenced-based psychological treatment to people diagnosed with mild-moderate depression and/or anxiety.
Eight years on and IAPT services in England are dealing with over 100,000 referrals a month, of which around 40% complete their course of treatment. “Recovery” is a key concept of the IAPT model and this is defined by two key self-reported outcome measures at the end of therapy:
In England around 45% of people treated by IAPT services “recover”.
I have been working for IAPT services as a therapist for a number of years and like the vast majority of my colleagues find the work both rewarding and challenging. Within IAPT services we therapists are tasked with a number of targets around “performance”. Not least of these is the drive to achieve a minimum recovery rate of 50% in all of our therapeutic work. It is well established that “severity at initial assessment” is a key determinant of “recovery”; people suffering mild/moderate depression and/or anxiety are more likely to reach IAPT defined “recovery” than those who start treatment with severe levels of depression and/or anxiety. Data from my own work and colleagues suggests that people referred for step 3 treatment (CBT, EMDR, IPT or counselling) are now predominately suffering with moderately severe or severe disorders as opposed to the mild to moderate sufferers that IAPT services are commissioned to treat.
Therapists in IAPT services have regularly suggested to me that it is not only the patient’s outcome scores which are increasing. Many of us “feel” that year-on-year the degree complexity of the presenting issues that we are treating is increasing concomitantly. As an academic and an Elf, I am well aware of the need to validate these “feelings” about the degree of complexity of presenting issues and was therefore really pleased when asked to blog about the impact of personality disorders on IAPT treatments for depression and anxiety. My colleagues and I have often speculated that people with personality difficulties would benefit less from IAPT treatment, and we were interested to see if this paper would support our hypothesis.
My blog focuses on a study carried out by academics from King’s College London in collaboration with an IAPT service provider (Southwark Psychological Therapies Service, South London and Maudsley NHS Foundation Trust) and looked at the impact of personality difficulties on depression/anxiety recovery rates in patients treated in an IAPT service.

IAPT services aim to achieve a minimum recovery rate of 50% in all therapeutic work.
Methods
One of the attractive aspects of this prospective cohort study is its simplicity. All IAPT services collect data (for the purposes of this study PHQ-9, GAD-7 and W&SAS a 5-item measure of impaired functioning) from every assessment and treatment session. Therefore, this study had the relatively simple task of additionally assessing, rating, monitoring and recording a measure of personality disorder! For this, the authors employed the 8-item validated Standardised Assessment of Personality Abbreviated Scale (SAPAS) – this was only used at assessment. Data was analysed by an array of statistical tests, all of which are well described and justified in the text of the original publication.
Results
SAPAS data was recoded for 1,249 adults during the period January 1st 2012 and December 31st 2012. After eliminating scores from people referred more than once and data from patients with no final outcome scores, the authors had an analytical sample size of 1,005.
The key findings from the analysis of this data were:
- People with higher SAPAS scores were more depressed, anxious and had a greater degree of functional impairment before treatment:
- PHQ-9 (r = .40, p < .001)
- GAD-7 (r = .41, SD = p < .001)
- W&SAS (r = .29, p < .001)
- SAPAS scores were also positively and significantly correlated with final scores (i.e. people with higher SAPAS scores were also more depressed, anxious and had a greater degree of functional impairment after treatment):
- PHQ-9 (r = .27, p < .001)
- GAD-7 (r = .30, p < .001)
- W&SAS (r= .26,p < .001)
- Higher SAPAS scores independently predicted a greater number of depression and anxiety symptoms, and greater functional impairment at last session.
- Higher SAPAS scores independently predicted less change on clinical (PHQ-9 and GAD-7) and functional (W&SAS) outcomes. The addition of SAPAS to the models was associated with small, significant improvements in R2. Models accounted for 20-30% of the variance.
- SAPAS score was a useful predictor of people who were likely to drop out of treatment or fail to engage; such patients had significantly higher SAPAS scores (M = 4.09, SD = 1.86, N = 349) than those who completed treatment (M = 3.70, SD = 1.92, N = 467) (t(814) = 2.86, p = .004).
Conclusions
In this large sample of IAPT attenders with anxiety and depression, the likely presence of co-morbid personality disorder, as indexed by the SAPAS, was independently associated with poorer outcomes at end of treatment.
Our models confirmed that personality difficulties are independently associated with poorer treatment outcomes in IAPT.

Individuals at risk of a personality disorder are less likely to have a favourable response to psychotherapy as delivered by an IAPT service.
Limitations
This, as the authors’ themselves identify, is a really pragmatic and elegantly simple study which adds real weight to the notion that referrals into IAPT service are complex and challenging. However, I’d like to have seen more detail on:
- The type of therapy used (although the authors did suggest most received CBT). They could have explored this in more detail.
- Psychotropic medication status: no mention was made about any correlation in any metric and prescriptions of psychotropic medication.
- Self-harming/Suicidal ideation and risk status. Could they have linked any self-harming behaviours (strongly evident in personality disorder populations) with SAPAS scores?
Summary
This study highlights the value of a simple to use, validated test to identify people referred into IAPT services who present with personality difficulties likely to hinder their recovery using the current or “traditional” IAPT model. The IAPT services I work for in the East Midlands have recently been revised and we now have the possibility of offering extended step 3 level therapy for specific comorbid presentations (such as Long Term Health Conditions): this is known as IAPT+.
I would advocate (based on this evidence) the use of SAPAS at assessment to identify patients with personality disorder traits as they too would benefit from the IAPT+ model.
Finally, I think the most likely reason that “we” IAPT service providers are seeing more complex presentations is linked to two changes in the provision of mental healthcare:
- More than 40% of people seen by IAPT services are self-referrals.
- People with a diagnosis of a personality disorder are no longer necessarily deemed appropriate for secondary mental healthcare.
As a caring practitioner I have often expressed my concerns about the lack of treatment available to people with a personality disorders. I can now only hope that this current publication acts as the catalyst for:
IAPT services…to consider providing additional training and supervision on the management of personality disorder, in order to ensure that therapists are able to provide effective interventions to individuals presenting with more complex psychological difficulties.

IAPT services may need to consider providing additional training and supervision on the management of personality disorder.
Links
Primary paper
Goddard E, Wingrove J, Moran P. (2015). The impact of comorbid personality problems on response to IAPT treatment for depression and anxiety. Behaviour Research and Therapy, 73, 1–7. doi:10.1016/j.brat.2015.07.006 [Abstract]
Other references
HSCIC (2015) Improving Access to Psychological Therapies (IAPT): Executive Summary, January 2015 final data (PDF). Health and Social Care Information Centre, 21 Apr 2015.
Personality disorders, IAPT treatment and recovery from depression and anxiety https://t.co/GjER9pBVxD via @sharethis
Personality disorders, IAPT treatment and recovery from depression and anxiety https://t.co/3iJOniH3xy #MentalHealth https://t.co/bEiBQRQ605
Personality disorders, IAPT treatment and recovery from depression and anxiety https://t.co/cnG8gY51Jn interesting blog
Today @121Therapy on impact of comorbid personality problems on response to IAPT treatment for depression/anxiety https://t.co/6MC70mKMEJ
@Mental_Elf @121Therapy Services for People with PD are sorely lacking. More so if you have an LD. Often nothing until secure services
@psychiatryofid @Mental_Elf @121Therapy Nope. The former is lacking completely. Trust me. Not even healthcare.
@AlresfordBear @Mental_Elf @121Therapy And we need to change that. There is work being done – read the article
@psychiatryofid @Mental_Elf @121Therapy Not enough. I believe education doesnt work with people who electively diagnostically overshadow.
@psychiatryofid @Mental_Elf @121Therapy Especially when the evidence of formative trauma is in place. Called oppression. Sack them.
@psychiatryofid @Mental_Elf @121Therapy Never quite understood how people who choose of free will to oppress against evidence can be taught.
@psychiatryofid @Mental_Elf @121Therapy There is a need for wider service provision though. Otherwise the stigma industry trundles on.
@AlresfordBear @Mental_Elf @121Therapy We need stories of recovery. It happens more often than HCPs think
@psychiatryofid @Mental_Elf @121Therapy Indeed. But its more about stories of seeing the linkages of the life course from child to adult.
@AlresfordBear @Mental_Elf @121Therapy How do you share that with HCPs without exposing yourself repeatedly?
@psychiatryofid @Mental_Elf @121Therapy And the formative traumas which still underpin daily human interactions.
@AlresfordBear @Mental_Elf @121Therapy RCPsych and RC emergency medicine working together to change this. Chipping away
@AlresfordBear @Mental_Elf @121Therapy Sadly often in spite of HCPs not because of
@psychiatryofid @121Therapy @AlresfordBear @Mental_Elf KUF Awareness training and TCs. People with PD modeling recovery blows staffs minds
@Keirwales @psychiatryofid @121Therapy @Mental_Elf Not sure as much as folk think.
@Keirwales @psychiatryofid @121Therapy @Mental_Elf Some experiences are seen as more valid than others.
@Keirwales @psychiatryofid @121Therapy @Mental_Elf Same as within services. Often unspoken.
@psychiatryofid @Mental_Elf @121Therapy I will wait to read the article. Perhaps too soon for me in terms of recent physical care access.
@AlresfordBear @Mental_Elf @121Therapy I’m sorry to hear that and I absolutely acknowledge that it happens
@psychiatryofid @Mental_Elf @121Therapy Dinnae worry. Isnt your fault, but it only happened at the weekend. A vital area to reflect on.
@psychiatryofid @Mental_Elf @121Therapy Thank you for bringing it to people`s attention :)
@Mental_Elf @121Therapy – I had PD for years, 1.5yrs in therapy and no longer considered PD but anxiety is still a large part of my life ?
@x_ioanna @121Therapy @Mental_Elf A.Bateman (mbt) “therapy reduces impulsive symptoms but still leaves people stuck” need 2 do more.
@Keirwales @121Therapy @Mental_Elf I couldn’t agree more, it was MBT I had, saved my life but left me in limbo with other issues..
So agree!! Am in NHS DBT tho been messed around continuously last 1.5 years with one therapist leaving & big gap then new therapist regularly cancelling/changing sessions, and no warning my time in group was up, and more! But, yes, agree helps somewhat with impulsivity but has resulted in worse anxiety & depression for me. And brought up memories I don’t know how to deal with. Needs to be followed by psychotherapy IMO. That ain’t gonna happen!!!!
Don’t miss @Mental_Elf blog: impact of personality problems on response to IAPT treatment of CMHDs https://t.co/aPTlSt5l1E
@Mental_Elf @121Therapy very interesting read!
Suggests patients with PD no longer necessarily deemed appropriate for 2nd care. Is this true? If so where? #GAPchat
https://t.co/HBJ70lqueQ
Interested in #IAPT & #mentalhealth? Read my @Mental_Elf blog on personality disorders and their impact on recovery https://t.co/aPTlSt5l1E
Also true for PTSD/complex trauma (anecdotal). The third sector has long been picking up the people who have found IAPT unhelpful. Often they need more complex holistic and longer term help currently only available in secondary care and not always accessible. IAPT plus sounds a great opportunity to address some of this and I hope this service is able to work closely with local secondary care services to ensure patients get all the help and expertise they need to reach a sustainable and meaningful recovery.
Interesting to read this article. Despite the paper ‘no longer a diagnosis of exclusion’ personality disorders are still considered as the dustbin diagnosis and within Hampshire at least are being refused treatment from both IAPT services and CMHT’s. This is also on the basis that their low mood is a clinical depression rather than a symptom of BPD. I would like someone to tell me who is meant to be helping these people?
In the service mentioned above which carried out the research, we (Southwark / Lambeth ie SLaM) have an entire CAG dedicated to mood and personality and we refer for intensive treatment for example using CAT or DBT
Thanks Marie, wonder if the authors are available to comment on my blog?
CAG = Clinical Academic Group?
http://www.slam.nhs.uk/about-us/clinical-academic-groups/mood,-anxiety-and-personality
@Mental_Elf in Final yr of NIHR funded PhD. Study explored via qual ints needs & exp of IAPT pts (SAPAS) & staff-results=compliment ^insight
@gazlamph can you let me have any more details?
@Mental_Elf excellent write up btw, gr8 to see unmet needs in IAPT raising in profile #IAPT+ an interesting concept :)
Kath Eccleston
Personality disorders, IAPT & recovery from depression/anxiety https://t.co/egljuktjTo
Personality disorders, IAPT treatment and recovery from depression and anxiety https://t.co/ZuarZdUHon via @sharethis
Personality disorders, IAPT treatment and recovery from depression and anxiety @Mental_Elf looks at the evidence https://t.co/kOKJtfQLs7
Personality disorders, IAPT treatment and recovery from depression and anxiety. https://t.co/kWwhWcExcP
Ppl at risk of personality disorder are less likely to have good response to psychotherapy delivered by IAPT https://t.co/6MC70mKMEJ
Personality disorders, IAPT treatment and recovery from depression and anxiety https://t.co/mL4tYzPiq1 via @sharethis Mentalhealth@GCU?
RT @Mental_Elf: IAPT services may need to consider providing additional training & supervision on management of personality disorder https:…
Don’t miss: Personality disorders, IAPT treatment and recovery from depression and anxiety https://t.co/6MC70mKMEJ #EBP
@Mental_Elf I agree that the experience of IAPT therapists are unfortunately being mirrored across most charitable therapeutic services
Personality disorders, IAPT treatment and recovery from depression and anxiety https://t.co/r0ksaFUopP via @sharethis
#IAPT #GAD #PHQ #SAPAS Personality disorders, IAPT treatment and recovery from depression and anxiety https://t.co/A83vET4Gnl via @sharethis
Personality disorders, IAPT treatment and recovery from depression and anxiety https://t.co/2nDkqhOlNr @doncasterccg @nhsbarnsleyccg
Personality disorders, IAPT treatment and recovery from depression and anxiety https://t.co/oLyUOy2G0q via @sharethis
Personality disorders, IAPT treatment and recovery from depression and anxiety https://t.co/daBQdMjtyJ via @sharethis
Personality disorders, IAPT treatment and recovery from depression and anxiety https://t.co/WY9uahPFQf via @sharethis #mentalhealth #MH
[…] 1Personality disorders, IAPT & recovery from depression/anxiety: The Mental Elf […]
Great article. One comment though, you mentioned that a high rate of self-referrals may have lead to an increase in complexity. This is not necessarily incorrect, however data from the service I work in show that those marked as self-referred have a higher recovery rate (by 6%) that those referred by GP, who in term, have a higher recovery rate than those referred from other mental health professional.
Thank you Kieran. It would be fascinating and helpful to know what split is with “PD” referrals (self/GP/others) as I suspect we (IAPT providers) currently receive referrals for people with personality disorder traits from GPs and especially from CMHTs. This really ties into the thread here and elsewhere, relating to “who should be offering treatment?”. Anecdotal evidence seems to be suggesting that PD remains the proverbial hot-potato. The answer in England seems to me to lie with the Commissioners – they need to commission appropriate services!
I agree that people with personality disorder (‘3.5s’) remain the both the hot potato and the elephant in the room – to mix metaphors. Unfortunately this population are often under diagnosed, tend not to self identify with the label and can be seen as less deserving of, or willing to engage in, treatment. I think there is a lot money to be saved in reducing crisis admissions etc if commissioners are willing to invest.
What if people who were given the diagnosis of borderline personality disorder could be viewed from a compassionate position by all who come into contact with them? As opposed to the ‘hot potato’ and the negative attitudes and therefore potential barriers to receive treatment? What if rather than the end result (diagnosis), we focussed more on cause? Why do some people develop borderline personality disorders? Are they born or created, through no fault of their own? One of the issues facing MH providers for decades is our own frustrations when working with clients who are given this diagnosis – they are in the too hard basket. But what if we developed a universal trauma informed approach to clients with this (and other) diagnosis? There is more and more neuroscientific evidence coming out almost daily that sheds quite a different light on MH issues (as opposed to the traditional viewpoints from the most powerful). Trauma informed Care appreciates the high prevalence of traumatic experiences in persons who receive mental health and addiction services. Trauma informed care has a thorough understanding of the profound neurological, biological, psychological and social effects of trauma and violence on the individual. (Jennings, 2004). Understanding trauma – when BAD things happen to GOOD people. First do no harm.
I agree with all of that.
Kieran, sorry a little late to the party here but do you have any data on self-referral in your service as regards PD patients? We are embarking on a feasibility study exploring the best treatment for common mental health disorders in patients with co-morbid PD and we have just completed a scoping study looking at trial evidence for the efficacy of various psychological treatments for dep. anx and co-morbid PD in IAPT. Would be enormously grateful for any thoughts.
Hi Lydia
I also apologise for the late reply. I do not have any data on this though would love to get it. Similarly getting some evidence on the degree of effectiveness of treatment of co-morbid common mental health problems would be very welcome.
[…] my last Mental Elf blog, I reviewed a study which showed that patients with comorbid Personality Disorders had poorer recovery from depression and anxiety when t…. In the blog I explored the possibility that IAPT services are increasingly receiving referrals […]