For anyone working in an Improving Access to Psychological Therapies (IAPT; now known as NHS Talking Therapies or NHSTT) service, the COVID-19 pandemic brought about rapid change in ways of working from 2020 onwards. Services needed to adapt almost overnight to providing evidence-based care either remotely or with significant adaptations if face-to-face (read Philippa Clery’s mega-blog on tele-mental health during the pandemic to learn more).

At the time, there was no precedent as to how clients would find these changes and what factors might predict how people accessed and engaged with these services. Service leads had concerns about whether these changes may introduce additional barriers for certain groups, such as digital poverty and the lack of confidential space in the home.

Referrals into services fell significantly during lockdown, but it is unclear exactly why this happened and what the different barriers for different groups may have been.

The present study by Verbist and colleagues (2023) is the first of its kind to examine retrospective data of clients referred to four NHSTT services in the North West of England, with the aims of:

1. Exploring whether the introduction of remote therapy affected access and engagement with IAPT services.
2. Investigating risk factors for non-attendance pre-, during and post-lockdown.

Methods

This study used an observational retrospective cohort design. During the timeframe of this research (23 Mar 2019 – 23 Sep 2021), 46,861 referrals into NHSTT services were screened. After exclusions based on access to treatment and suitability, the final sample included 9,676 clients, with:

• 2,913 accessing services before lockdown (23 Mar – 23 Sep 2019)
• 3,238 accessing services during lockdown (23 Mar – 23 Sep 2020)
• 3,525 accessing services after lockdown (23 Mar – 23 Sep 2021)

Each referral had their demographics, placement within the stepped-care model, access to and engagement with NHSTT treatment monitored. Due to the amount of missing data related to disability status and provisional diagnosis, these factors were not included.

The study defined ‘entering NHSTT treatment’ as someone who attended one treatment session, ‘access to treatment’ as someone who attended two or more treatment sessions, and ‘engagement with treatment’ as someone who had a planned discharge to their referral.

Statistical tests then compared whether these factors affected access and engagement to NHSTT treatment differently across the three timeframes of the study.

Results

Access to treatment

Across the 3 groups, findings demonstrated that significantly more people entered NHSTT treatment after lockdown compared with before/during lockdowns (before: 1,757; during: 1,936; after: 2,275; p < .001). No demographics made up this significant increase.

Before lockdown

When exploring the factors that affected access to treatment before lockdown, the researchers found:

• Clients who declined to state their sexuality accessed treatment less than heterosexual clients (p = .01).
• Clients without a reported long-term physical health condition (LTC) accessed treatment less than those with an LTC (p = .01).

During lockdown

• Not accessing treatment was more common among clients whose first language was not English compared to those who did speak English as a first language (p = 0.01).
• Unemployed clients more commonly did not access treatment in comparison to employed clients (p < .001); this was also identified as a risk factor, with unemployed clients almost 1.5 times less likely than employed clients to access treatment (OR = 1.36, 95% CI [1.1 to 1.66], p < .001).
• Patients from a Black ethnic background accessed treatment more than White British clients (p < .001), with White background also being considered a risk factor to treatment non-access (OR = 2.04, 95% CI [1.29 to 3.21], p = .002).
• Perinatal patients accessed treatment more than non-perinatal clients (p = .02), with non-perinatal clients serving as a risk factor for failing to access treatment (OR = 1.47, 95% CI [1.13 to 1.92], p = 0.005).

After lockdown

• Males more commonly didn’t access treatment in comparison to females (p < .03).
• Unemployed clients more commonly didn’t access treatment in comparison to employed/student clients (p < .001), with unemployment being a risk factor for failing to access treatment (OR = 1.68, 95% CI [1.4 to 2.02], p < .001).

Engagement with treatment

When exploring the factors that affected engagement with NHSTT treatment, being young (<34 years), perinatal, unemployed, and clients taking psychotropic medication were each more likely to disengage with NHSTT treatment regardless of timeframe.

Before lockdown, being younger (OR = 0.98, 95% CI [0.98 to 0.99], p = .01), unemployed, (OR = 1.74, 95% CI [1.33 to 2.31], p < .001), homemakers (OR = 3.13, 95% CI [1.46 to 6.69], p = .003), perinatal (OR = 1.8, 95% CI [1.22 to 2.51], p = .002), or on medication (OR = 1.47, 95% CI [1.15 to 1.88], p < .001) were risk factors for disengagement.

During lockdown, findings were similar, except that patients with a long-term condition (LTC) were more likely to commit to treatment and have a planned outcome (OR = 0.74, 95% CI [0.56 to 0.98], p = .03), making non-LTC status an additional risk factor for treatment disengagement.

After lockdown, similar trends were seen in risk factors regarding youth and employment status. However, in this group, neither gender, perinatal status, ethnicity, or presence of mediation significantly contributed to treatment disengagement.

Conclusions

Verbist et al. (2023) found that access to and engagement with NHSTT services is significantly higher after lockdown than it was before or during. The authors note that higher access rates could be linked to lower waiting times during lockdown, which were achieved due to lower levels of referrals into services at that period.

In addition, perinatal clients and Black clients were significantly more likely to access treatment during lockdown than before or after lockdown, and younger age and unemployment were consistent predictors of unplanned discharge at all stages of the study. These findings are consistent with the wider literature and the context of the pandemic, such as George Floyd’s murder and the rapid decrease in young people’s mental health.

It is noted that the number of clients who were taking psychotropic medications increased over the study period, which requires further research and exploration.

Strengths and limitations

Strengths

One strength is that the study controlled for waiting times when analysing their data. It is likely that this could affect a client’s access/engagement with NHSTT regardless of their demographics, so accounting for this improves the validity of comparisons made between different groups within the study.

Similarly, as discussed by the authors, this was the first study to explore unique timeframes within the COVID-19 pandemic to assess their effect on access/engagement. This new information provides services with a wealth of data to suggest which populations experienced barriers at different points during the pandemic, and who may require additional attention to improve access/engagement.

Limitations

• No consideration was taken regarding step-ups within NHSTT services (e.g., transitioning from guided self-help to Cognitive Behavioural Therapy). Certain demographics are more prone to step-ups within NHSTT, such as clients with a diagnosed long-term condition (Chan & Adams, 2014), and typical service waiting times might mean some demographics saw more data exclusion than others due to this combination.
• This paper considers COVID-19 broadly, despite different restrictions placed in different areas of the UK between 2019 and 2021. This could have provided additional challenge to engagement based on a client’s location in England, reducing the comparability of data from different NHSTT services.
• Likewise, the authors highlight that all participants come from the same geographical area (the North West of England), and there may be issues in generalising these findings to England as a whole.
• Disability status and preliminary diagnoses were not considered in this study due to insufficient data; either could impact client engagement if not sufficiently adapted for.
• Digital poverty was not controlled for, and although the study notes that there is broad satisfaction with video consultation as a communication medium for therapy, this could only have been ascertained from those who were accessing the service.
• Finally, therapist effects were not measured during this study, despite the relationship between therapist and client being a major contributor to a client’s engagement. This could reduce the validity of some of the comparisons made.

Implications for practice

Many factors need to be considered when exploring how and why different groups in the community accessed NHSTT services before, during and after the pandemic. Consequently, researchers are actively exploring facets of mental health care delivery that should change in a post-pandemic world (Monero et al., 2020). It is vital that clinical service providers and commissioners use the knowledge gained from studies such as this to consider how to provide effective treatments for different demographic groups accessing NHSTT.

Higher access rates are hopefully a feature of people finding services more accessible, or potentially due to lower waiting times during lockdown. Alongside that though, it would be interesting to build on this research by assessing the quality of service delivery during this period of time, rather than solely its quantity. This could be achieved by incorporating problem descriptors and recovery rates identified through the monitoring of patient-reported outcome measures typically used in NHSTT services to gauge symptom prevalence/intensity (Gyani et al., 2013).

The cornerstone of this study is it’s contribution to our learning about what works for whom – and when it works best. Having personally discussed with many clients and ex-clients the changes to service provision that COVID-19 brought, the recurring main theme is the importance of patient choice and the concern that services who are still working predominantly or exclusively remotely are not offering this. We have gained a lot from digital developments during this period, which has increased access to therapy for many people; but we must not let this overshadow the preferences of others who may need other adaptations to ensure they can access services in a timely and appropriate way. Here, the old adage of ‘just because we can, doesn’t mean we should’ rings true.

Statement of interests

None.

Links

Primary paper

Verbist, I. L., Fabian, H., Huey, D., Brooks, H., Lovell, K., & Blakemore, A. (2023). Exploring access and engagement with Improving Access to Psychological Therapies (IAPT) services, before, during, and after the COVID-19 lockdown: A service evaluation in the Northwest of England. Psychotherapy Research, 1-12.

Other references

Chan, S. W., & Adams, M. (2014). Service use, drop-out rate and clinical outcomes: a comparison between high and low intensity treatments in an IAPT service. Behavioural and Cognitive Psychotherapy, 42(6), 747-759.

Clery, P. (2022). Telemental health: mega-blog on remote mental health care during the pandemic. The Mental Elf.

Gyani, A., Shafran, R., Layard, R., & Clark, D. M. (2013). Enhancing recovery rates: lessons from year one of IAPT. Behaviour Research and Therapy, 51(9), 597-606.

Moreno, C., Wykes, T., Galderisi, S., Nordentoft, M., Crossley, N., Jones, N., … & Arango, C. (2020). How mental health care should change as a consequence of the COVID-19 pandemic. The Lancet Psychiatry, 7(9), 813-824.

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