The journey to recovery following discharge from NHS Talking Therapy Services

The negative implications of anxiety and depression are well known, and despite treatments being effective and people achieving recovery, many face several challenges to maintain treatment gains over time. This article summarises the research conducted in NHS Talking Therapies so far and introduces the NIHR funded CO-IMPROVE research project.

Anxiety, depression, and recovery in NHS talking therapies

The global prevalence of anxiety and depression is exceptionally high with data indicating 280 million people living with depression and 301 million living with an anxiety disorder, and its implications on social and occupational functioning and mortality are well known.

The NHS has created a world-leading psychological therapy programme, formerly known as 'Improving Access to Psychological Therapy (IAPT)' and currently rebranded as 'NHS Talking Therapies', to help people with depression and anxiety. These services follow National Institute for Health and Care Excellence (NICE) guidelines recommending the delivery of care based on a stepped-care model, meaning people will be provided the least intrusive and most effective intervention first. 
 
In May 2023, NHS Talking Therapies reported that 50.5% of referrals moved to recovery highlighting the considerable impact on short-term recovery. 
 
NHS Talking Therapies defines recovery as achieved when a person who began treatment with symptoms considered a clinical case (i.e., their symptoms exceed a certain threshold as measured by appropriate scoring tools) ends treatment as not a clinical case (symptoms below the defined threshold). 
 
Less is known about long-term recovery and the effectiveness of treatment following discharge due to follow-up data not needing to be regularly collected nationally. Evidence on treatment benefits over time is limited to research data conducted in NHS Talking Therapies and is scarce. 

What do we know about patients following discharge from NHS Talking Therapies services?

From when the IAPT programme started in 2008 there have been 7 published papers providing information about patients after being discharged from NHS Talking Therapies services. Throughout the years various researchers have sought to understand whether the immediate success when completing treatment remains beyond the therapy setting and provided information about relapse rates and factors influencing recovery following discharge. 
 
Research shows that NHS Talking Therapy services proved effective at achieving recovery following acute phase treatment, where 50% of patients or more recovered following low or high intensity treatment (NHS Talking Therapies, May 2023). However, symptoms of anxiety and depression increased within 16-72 weeks following discharge from treatment. 
 
One study focusing on low-intensity psychological treatments found that more than 50% of patients who completed treatment relapsed within one year, with the majority doing so within the first six months. Other studies did not differentiate between low or high intensity treatment and reported recovery rates dropped post-treatment. 
 
Another study highlighted that patients are more likely to return to the same service within the first five years following treatment, with numbers increasing yearly. Approximately 27% of all therapy sessions offered in one service were administered to returning patients, indicating that services need to allocate resources to provide further treatment to returning patients. Evidence highlights the need to improve long term benefits for patients following psychological treatment. 

What happens following discharge that may influence symptoms to return?

Three studies have explored the predictors of relapse to understand the distinct features that inhibit individuals from sustaining mental wellbeing including trouble concentrating, low levels of attentional control, young age, unemployment and a non-linear treatment response.
 
The gradual process in which relapse occurs and the significant number of people who relapse following treatment suggests that more needs to be done to maintain treatment gains over time.

Why do we need research on patients following treatment?

• Current data suggests that attention is urgently needed to prevent relapse for over 300,000 patients annually
• Ensuring long term benefits from psychological interventions has potential for concomitant gains in direct and indirect service expenditure
• Delivering high quality as well as effective services is recognised as a fundamental step in strengthening the capacity of future healthcare systems 

The CO-IMPROVE Project

The CO-IMPROVE project is being funded by the National Institute for Health Research (NIHR), Research for Patient Benefit grant as a response to the Mental Health theme call in the North of England. Its main aim is to understand how to maintain treatment benefits and reduce risk of relapse and/or address difficulties in a timely manner in routine provision following successful low-intensity treatment for anxiety and/or depression provided by NHS Talking Therapies services.

The project comprises three phases involving collaborating with multiple stakeholders:

1. To gather an in-depth understanding of factors that contribute to/ameliorate relapse following low-intensity treatment (Phase 1) 
2. To co-develop a transdiagnostic toolkit to support the journey towards recovery following discharge from low-intensity treatment (Phase 2)
3. To review and finalise the toolkit and have it ready for implementation in a future research project (Phase 3)

The progress so far

The project is in its first phase, and we are grateful for the engagement and support provided so far by four NHS Trusts located in the North of England. 

The recruitment process and interviews are ongoing. However, from conversations with key stakeholders, including clinical academics, service leads and senior psychological wellbeing practitioners and discussions with our patient and public involvement advisory group, the journey to recovery is expressed to be challenging and of great importance within and beyond treatment.

Future plans

The CO-IMPROVE project will continue by working on completing each of the three phases of the project to ultimately develop a transdiagnostic toolkit to support the journey towards recovery following low-intensity interventions.

We welcome everyone with interests in this area to work in collaboration with us. 

Key Reading List

Understand more about stepped care and NICE guidance

Find out more about NHS Talking Therapies services or find an NHS talking therapy service in your area

Research conducted in NHS Talking Therapies following patient discharge:

• Improving access to psychological therapy
• How durable is the effect of low intensity CBT for depression and anxiety?
• The WYLOW Longitudinal Cohort Study
• Exploring relapse after CBT
• Attentional Control as a Predictor of Response to Psychological Treatment for Depression and Relapse
• Dynamic prediction and identification of cases at risk of relapse following CBT
• An investigation of treatment return after psychological therapy for depression and anxiety

Author bio

Saher Nawaz graduated with a BSc (Hons) in Psychology in 2021 and an MSc in Health Psychology in 2022 at The University of Manchester where she currently works as a researcher on the CO-IMPROVE project.

Cintia Faija completed her PhD in Clinical Psychology in 2016 at The University of Manchester and since then has worked in research applied to mental health and psychological therapy. She is the principal investigator of the CO-IMPROVE project and a Lecturer in Clinical Psychology at The University of Liverpool. 

To hear more or get involved, contact Saher at: [email protected]

Twitter/X: @IaptResearch
Instagram: iapt.research

With thanks to Samina Begum, a member of the Patient and Public Involvement Advisory group, for her engagement and collaboration on this article.