“I was considering not picking up the phone today”, is a phrase that no longer surprises me when contacting a client for the first time.
Reaching out for help, particularly for our mental health, can be a daunting task, especially given the many barriers those seeking support may face.
Within any given week, one in six adults in England report symptoms of common mental health disorders (CMDs; Baker, 2020). However, as the prevalence of CMDs rise, accessing support through primary care remains a difficulty for many.
Medication and evidence-based psychological treatments (EBPT) are often recommended to help those experiencing CMDs like depression and anxiety, with EBPT being preferred. “I would rather try therapy before I try medication”, is an expression I often hear from clients.
We know that there are barriers to accessing mental health services – so what do we do about it? In an attempt to improve access to primary care, the unique initiative of Improving Access to Psychological Therapies (IAPT) was introduced in England in 2008. “This is great!”, we may say. However, despite IAPT offering free and easily accessible EBPT, treatment gaps persist, with studies showing that 25% of IAPT appointments are missed and 42% of patients only attend one treatment session (Davis et al., 2020). But why does this happen?
In order to improve our understanding of the barriers faced, it is only fair that we walk a mile in our patients’ shoes. Whether you are a healthcare professional (HCP), a client, or some who has sat on both sides of the therapy room, this up-to-date qualitative systematic review and meta-synthesis by Tunks and colleagues (2023) provides useful findings regarding the barriers and facilitators to accessing EBPT in primary care.
Seven electronic databases were searched to gather papers dated from 2008 (the establishment of IAPT) to 2022. Searches were limited to studies conducted in England and written in English.
The first author conducted title-abstract and full-text screening on articles returned from the initial searches, adhering to inclusion and exclusion criteria. Data then extracted and synthesised, using an approach informed by thematic analysis.
Study quality was appraised using adapted CASP checklists. No studies were removed on the grounds of quality, as all met the majority of criteria.
30 studies were included in the systematic review, with a combined total of 610 participants. The average age of the sample was 33.5 years, with ages ranging from 18 to 92 years. Studies sampled patients from different demographic groups including refugees, veterans, and black Caribbean communities.
Participants were most commonly women (73 %) of White British ethnicity (59%). The type of CMDs that studies most frequently focused upon were perinatal depression (n = 8) and mixed anxiety and depression disorders (n = 6).
Thematic synthesis generated three themes comprised of seven subthemes.
Theme 1: Journey to the first consultation
Knowledge and understanding of CMDs was reported as a barrier to accessing primary care, with some patients labelling their CMD as: “it is just the type of character I am” (Chew-Graham et al., 2009), whilst others stated that their CMD was a natural response to stressors: “I figured that that seems a natural response” (Williams et al., 2016).
Stigma placed upon CMDs was reported as an additional barrier, with some participants reporting; “you sort of hide it, don’t you? You’re just, like, embarrassed” (Oh et al., 2020) due to the fear of discrimination, resulting in “silent suffering” (Kovandˇzi´c et al., 2011).
Other participants reported that help-seeking was not their first step. Rather, they reported taking problems into their own hands, such as practicing self-help strategies (e.g., yoga, mindfulness) as they did not believe they were suffering ‘enough’ to put additional strain upon the NHS. Others “doubted they would experience any benefits” if they did reach out (Christodoulou et al., 2018), therefore didn’t. It is concerning that some waited until they “couldn’t cope” before they sought professional help (Robinson et al., 2017) .
Theme 2: Primary care is not the place for CMDs
Patients viewed primary care as a place to seek support for physical health difficulties, rather than CMDs. This manifested in multiple ways; for example, the perception that HCPs had limited power and knowledge regarding CMDs: “He said, ‘you haven’t got postnatal depression. You’re too cheerful and bright and laughing” (Edge, 2008). Some participants reported a lack of knowledge about services, whilst others had a negative or stigmatised view of primary care; “I used to fear all people in uniforms and all sort of sounds” (Bahu, 2019).
Theme 3: The healthcare professional and patient interaction
When at our most vulnerable, we wish to talk with someone who listens and provides empathy. However, participants emphasised the fear that this may not be the case, which prevented some from disclosing, and resulted in others withdrawing from treatment completely. One particular participant stated that they did not know who they were speaking with, so questioned “why am I going to talk to that person?” (Oh et al, 2020).
This up-to-date review provides knowledge of the barriers and facilitators to accessing EBPT via primary care and IAPT for CMDs, with the authors concluding that:
Knowledge, attitudinal, systemic and relational barriers and facilitators were identified as stemming from the patient, HCPs and services.
Despite IAPT’s aim to offer easier access, barriers remained as participants reported that they did not view primary care as a place supportive of CMDs or had little hope that HCPs would have the knowledge or ability to meet their needs.
Further, although stigma towards mental health appears to be lifting, this review clarifies that it is still a prevalent concern and preventative factor in help-seeking. Tunks and colleagues (2023) recommend that “future research should focus on developing stigma reduction initiatives”.
Strengths and limitations
- The study reported qualitative findings, with verbatim quotes illustrating the lived experiences of participants. This provides them with a voice, whilst also allowing HCPs the opportunity to walk in their patients’ shoes and gain a better understanding of their perspectives.
- This review provides an element of uniqueness by exploring barriers experienced prior to treatment in comparison to previous research, which has predominately focused on the appropriateness and engagement whilst in treatment (Harrison et al., 2019; Verbist et al., 2023).
- Reflexivity was heavily considered throughout this review, with the first author reflecting throughout the analysis in order to highlight the potential impact of their own biases and experiences.
- The sample was diverse, including perspectives from refugee, veteran, and Black Caribbean communities.
- The review was pre-registered on PROSPERO and followed best practice guidelines.
- It must be noted that this review is limited in global transferability as it is focuses solely on England. However, due to the nature of England’s IAPT service, this was done purposefully by the authors of this review and made sense in the context of the review.
- The included studies most commonly focused on patients’ interactions with primary care, rather than initial access to IAPT, limiting the scope of this review.
- Participant-researcher relationships are integral to gaining rich, in-depth data, and so researchers often strive to develop a close relationship with their participants. However, specific to the studies in this review, the relationship between the participant and researcher lacked consideration.
- Cohen’s kappa for the quality assessment was moderate, meaning that there was some disagreement between researchers regarding whether a study met the criteria or not. It may be debated that this was because of the natural complexity of qualitative research. However, only 10% of the studies were double-screened – best practice recommends full screening, particularly if kappa levels are only moderate.
Implications for practice
This review provides the opportunity for HCPs and services to consider adaptations to their approach in order to make seeking support a less daunting and disheartening experience for patients.
Additional training opportunities for HCPs appears necessary, as findings show that a lack of HCP understanding towards CMDs was a preventative factor. Such training should include helping HCPs to identify less visible symptoms of CMDs, alongside how to pay attention to what is also not being said. Updated training should be offered to primary care professionals such as GPs in order to help build better relationships with their clients and understand their unique experiences.
The introduction of IAPT aimed to offer early treatment for CMD – however, this review tells us that there remain challenges. Therefore, there is a need for IAPT services to consider how they can more effectively reach out to the communities they serve, informing the public of what they offer, how to access such services, and what to expect once referred.
This review also emphasises the need for HCPs to focus on the therapeutic alliance and expand their knowledge of CMD, as HCP knowledge of their patients’ CMD will likely keep the therapeutic alliance afloat. Likewise, the client must be educated on the symptoms of CMDs, rather than labelling their symptoms as just a characteristic of their personality – this undermines the significance of their CMD and decreases their chances of seeking support. Future research should explore how psychoeducation focused on the symptoms of CMD can be provided prior to treatment, potentially through a public mental health approach.
Client perspectives are invaluable and should be prioritised when considering how to improve primary care. It must be noted that mental health is so very unique to the human being, making it practically impossible to gather views from every individual experiencing a CMD. However, we would hope that by providing a good experience for one individual, “word of mouth” may get around that seeking support was not as difficult or daunting than they once thought, subsequently encouraging others to do the same.
Statement of interests
I have no association with the authors of the reviewed paper.
Tunks, A., Berry, C., Strauss, C., Nyikavaranda, P., & Ford, E. (2023). Patients’ perspectives of barriers and facilitators to accessing support through primary care for common mental health problems in England: A systematic review. Journal of Affective Disorders, 338, 329-340.
Bahu, M. (2019). War, trauma and culture: working with Tamil refugees and asylum seekers using culturally adapted CBT. The Cognitive Behaviour Therapist, 12, e46.
Baker, C. (2020). Mental health statistics: prevalence, services and funding in England. In: Briefing Paper Number 6988, 6988. House of Commons Library, UK Parliament.
Chew-Graham, C. A., Sharp, D., Chamberlain, E., Folkes, L., & Turner, K. M. (2009). Disclosure of symptoms of postnatal depression, the perspectives of health professionals and women: a qualitative study. BMC Family Practice, 10, 1-9.
Christodoulou, V., Fortune, L., Arslan, G., & Canan, K. (2018). Turkish-speaking service-user experience of guided self-help in an improving access to psychological therapies service: Using discovery interviews to improve services. Qualitative Report, 23(9), 2205-2221.
Davis, A., Smith, T., Talbot, J., Eldridge, C., & Betts, D. (2020). Predicting patient engagement in IAPT services: a statistical analysis of electronic health records. BMJ Ment Health, 23(1), 8-14.
Edge, D. (2008). ‘We don’t see Black women here’: an exploration of the absence of Black Caribbean women from clinical and epidemiological data on perinatal depression in the UK. Midwifery, 24(4), 379-389.
Kovandžić, M., Chew-Graham, C., Reeve, J., Edwards, S., Peters, S., Edge, D., … & Dowrick, C. (2011). Access to primary mental health care for hard-to-reach groups: from ‘silent suffering’to ‘making it work’. Social Science & Medicine, 72(5), 763-772.
Harrison, P., Hardy, G. E., & Barkham, M. (2019). The relationship between expected engagement and talking therapy outcome. Clinical Psychology & Psychotherapy, 26(4), 492–501.
Oh, S., Chew-Graham, C. A., Silverwood, V., Shaheen, S. A., Walsh-House, J., Sumathipala, A., & Kingstone, T. (2020). Exploring women’s experiences of identifying, negotiating and managing perinatal anxiety: a qualitative study. BMJ Open, 10(12), e040731.
Robinson, K. J., Rose, D., & Salkovskis, P. M. (2017). Seeking help for obsessive compulsive disorder (OCD): a qualitative study of the enablers and barriers conducted by a researcher with personal experience of OCD. Psychology and Psychotherapy: Theory, Research and Practice, 90(2), 193-211.
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.
Williams, C. J., Turner, K. M., Burns, A., Evans, J., & Bennert, K. (2016). Midwives and women׳ s views on using UK recommended depression case finding questions in antenatal care. Midwifery, 35, 39-46.