Commissioning guides
Published 01 November 2011

Commissioning stepped care for people with common mental health disorders

This is an extract from the commissioning guide. The complete commissioning guide is available at www.nice.org.uk/guidance/cmg41

4 Assessing service levels for people with common mental health disorders

NICE clinical guideline 123 recommendation 1.1.1.7 states that commissioners and their partners should conduct a local needs assessment to estimate local service need, plan capacity and develop plans to improve the accessibility and inclusivity of services. This assessment should include:

  • prevalence and incidence of common mental health disorders (see section 4.1)

  • additional factors that influence local service need (see section 4.2)

  • existing local practice and determination of optimum capacity (see section 4.3).

Commissioners should ensure that local needs assessment takes into account the views and experience of local service users. Commissioners may wish to refer to the NICE quality standard on service user experience in adult mental health.

Commissioners and their partners should work with the local health and wellbeing board, public health team and local authority, to ensure that their joint strategic needs assessment (JSNA) and/or health and wellbeing plans include information on the local prevalence of common mental health disorders, service capacity and demand. A wide range of data may be used for the needs assessment.

Commissioners should ensure that they engage with the public and service users when developing their needs assessment in order to understand service-user experience of the local care pathway, and local barriers to accessing treatment. This information should be used to inform commissioning plans and to improve the accessibility of local services.

4.1 Prevalence and incidence of common mental health disorders

Available data suggest that the indicative benchmark rate for common mental health disorders is 17.7%, or 17,700 per 100,000 of the population aged 18 years and older.

For a standard population of 100,000 around 79%, or 79,000, will be aged 18 or older. Of this population 17.7%, or around 14,000, will have a common mental health disorder.

Service capacity should be locally defined, but it should assume that around 15%, or 2100 per 100,000 population, of those aged 18 or older will need access to treatment at steps 2 or 3 each year.

A small proportion (around 5% of the prevalent population, or 900 per 100,000 population [0.9%] aged 18 or over) will have more complex needs and need interventions at step 4 or above.

For this guide for commissioners and benchmark, common mental health disorders are defined as:

  • depression

  • generalised anxiety disorder

  • mixed depression and anxiety

  • panic disorder

  • obsessive-compulsive disorder

  • phobias (including social anxiety disorder (social phobia))

  • post-traumatic stress disorder.

Commissioners can use section 7 of this guide to determine the level of service that might be needed locally and to calculate the cost of commissioning the service using the indicative benchmark and/or local data.

4.1.1 Treated and untreated common mental health disorders

The Adult Psychiatric Morbidity Survey (APMS) provides data on the prevalence of both treated and untreated common mental health disorders in the English adult population aged 16 and older[16]. For the purpose of this benchmark and to be consistent with published NICE guidance, the proportions in the APMS have been applied to the England population aged 18 or older.

The APMS defines common mental health disorders as potentially comorbid mental conditions that cause marked emotional distress and interfere with daily function, but do not usually affect insight or cognition. They comprise different types of depression and anxiety[17]. The APMS does not include post-traumatic stress disorder in its definition of a common mental health disorder.

The APMS found that 16.2% of adults met the diagnostic criteria for at least one common mental health disorder (excluding post-traumatic stress disorder). Table 2 sets out the conditions and the 1-week prevalence rate. Note that some people may be diagnosed with more than one condition. A person diagnosed with more than one condition will be counted only once in the overall prevalence, so the sum of the individual conditions will be higher than the stated prevalence.

Table 2 APMS 1-week prevalence rates of common mental health disorders18

Condition

1-week prevalence rate

Generalised anxiety disorder

4.4%

Depressive episode (mild moderate and severe)

2.3%

Phobias

1.4%

Obsessive and compulsive disorder

1.1%

Panic disorder

1.1%

Mixed anxiety and depressive disorder

9%

The APMS also found that 3% of adults met the diagnostic criteria for post-traumatic stress disorder. Around half of these will have a comorbid common mental health disorder[18]. For the purpose of this benchmark, it is assumed that 1.5% of the population will have post-traumatic stress disorder on top of the 16.2% of people with other common mental health disorders. Therefore the 1-week prevalence of common mental health disorders is calculated to be 17.7% of the population aged 18 and older.

The prevalence and incidence of common mental health disorders are likely to vary locally. Commissioners will need to consider local demographics when carrying out their needs analysis; the data in table 2 is an estimate of the numbers likely to be diagnosed with each condition at any point in time. However, not everyone with these conditions will seek or agree to treatment, some may have previously received it, and a few cases will resolve spontaneously.

Mixed anxiety and depression is by far the most common condition in the community. However, this is a subsyndromal condition that often has a short lifespan and a high rate of spontaneous remission.

For the purposes of this benchmark, it is estimated that up to 60% of the prevalent population are not identified or not seeking treatment (see section 4.3).

4.1.2 Diagnosed common mental health disorders

Data extracted from IMS Disease Analyser, a database that holds data from a sample of GP practice systems, shows the recorded incidence of common mental health disorders is 1.23% (service-users aged 18 years and older with a first diagnosis of a common mental health disorder during 2010/11). The number of people with a diagnosed disorder is likely to be an underestimate of the true level of need, because not everyone will be diagnosed or have sought treatment.

Around 25% of people in England, aged 18 years or older, have at some point had a diagnosis of a common mental health disorder. Of those, about 27% were being prescribed antidepressants in 2010/11, around 5 times as many as were receiving psychological interventions (see table 3).

Table 3 Current treatments for diagnoses of common mental health disorders

Treatment in the study year (2010/11)

% of those with a CMHD

CMHD and prescribed antidepressantsa

26.70%

CMHD and prescribed antipsychoticsa

1.40%

CMHD and prescribed psychological treatmentb

5.30%

CMHD and prescribed self helpb

0.50%

CMHD and prescribed anxiolyticsa

3.60%

Abbreviations: CMHD, common mental health disorder

a Problem linked to therapy.

b treatment cannot be linked to the problem.

4.2 Additional factors that influence local service need

Commissioners will need to consider local demographics when carrying out their needs analysis. The following equalities and demographic factors can have a significant effect on the local need and uptake of common mental health services:

  • age and gender (see section 4.2.1)

  • black and minority ethnic groups (see section 4.2.2)

  • persons in prison or in contact with the criminal justice system (see section 4.2.3)

  • service and ex-service personnel (see section 4.2.4)

  • deprivation (see section 4.2.5)

  • housing and homelessness (see section 4.2.6)

  • refugees and asylum seekers (see section 4.2.7)

  • long term conditions (see section 4.2.8)

  • lesbian, gay, bisexual and transgender people (see section 4.2.9)

  • regional and local variation (see section 4.2.10).

Commissioners should use information on these factors to assess local need and to plan for inclusive local services.

4.2.1 Age and gender

The prevalence of common mental health disorders varies widely with age. Prevalence peaks between the ages of 35 and 44 for men and between 45 and 54 for women, then declines sharply. This may have a significant impact on the level of need in communities that have a higher or lower than average proportion of their population in these age groups.

Figure 5 Prevalence of common mental health disorders by age and gender18,[19]

Overall, the prevalence of common mental health disorders is highest among those aged 45–54 and lowest in those aged 75 or older. Studies in other high-income countries also show that, although people aged 55 years and older have more chronic physical health conditions and are more likely to face the loss of partners, friends and family, this age group suffers less anxiety and depression than younger people[20],[21]. The lower recorded rates of common mental health disorders in older people could result from underdiagnosis or an inappropriate method for measuring disorders in older people. Many surveys of common mental health disorders, including the APMS, measure only people living in private households and therefore do not account for the level of need in residential homes or care settings.

The review 'Improving access to psychological therapies: a review of the progress made by sites in the first roll-out year' showed that 4% of people receiving psychological interventions were 65 or older and overall the gender ratio was just under two women to each man[22].

Other studies have found an increased prevalence of common mental health disorders in older people. One study found that depression affects one in five older people living in the community and two in five living in care homes[23].

4.2.2 Black and minority ethnic groups

Figure 6 looks at common mental health disorders for men and women, split by ethnicity[20],[24]. In each ethnic group women have a higher prevalence of common mental health disorders than men. In particular, communities with a high proportion of south Asian women may need additional capacity.

Figure 6 Common mental health disorders, age standardised by ethnicity and gender[25]

The review 'Improving access to psychological therapies: a review of the progress made by sites in the first roll-out year' showed that people from Asian and black ethnic groups were under‐represented in psychological intervention services, as were men from white minority ethnic groups[23].

4.2.3 Persons in prison or in contact with the criminal justice system

Up to 200,000 people move in and out of prison each year, many staying only a few months[26]. Prisoners have both an extremely high prevalence and complexity of mental disorders, often combined with vulnerability factors such as homelessness or a history of drug or alcohol misuse. They include some of the most socially excluded members of society and can present a considerable challenge to those charged with their care.

Although now more than 10 years old, the survey for the Office for National Statistics on psychiatric morbidity among prisoners[27] was a comprehensive attempt to provide robust baseline information about the prevalence of psychiatric disorders among remand[28] and sentenced[29] prisoners. Table 4 summarises the 1-week prevalence of common mental health disorders split by condition among this group.

Table 4 Information about the prevalence of psychiatric disorders in prisons29

 

Male remand %

Male sentenced %

Female remand %

Female sentenced %

Depressive episode

17

8

11

11

Generalised anxiety disorder

11

8

11

11

Mixed anxiety and depressive disorder

26

19

36

31

Phobia

10

6

18

11

Obsessive-compulsive disorder

10

7

12

7

Panic

6

3

5

4

Any common mental health disorder

59

40

76

63

The prevalence rates of these conditions for male remand prisoners were higher than those for their sentenced counterparts, although the differences for generalised anxiety disorder and obsessive-compulsive disorder were not significant.

Female prisoners in this survey were significantly more likely than men to suffer from a common mental health disorder, as is the case in the general population[26]. While 59% of remand and 40% of sentenced male prisoners in the sample had a common mental health disorder, the corresponding figures for women were 76% and 63%. For both sexes, remand prisoners were significantly more likely to have a common mental health disorder. These figures are much higher than the equivalent figures is the general household survey (see section 4.1.1).

4.2.4 Service and ex-service personnel

The 2009 study 'The prevalence of common mental disorders and post-traumatic stress disorder in the UK military' showed post-traumatic stress disorder prevalence was higher among serving personnel (regular and reserve) and ex-service personnel than in the general population[30] (4.8% for service and ex-service personnel, compared with 3% for the general population[31]). The prevalence of other common mental health disorders was also similar to or higher than that in the general population, as shown in table 5).

Table 5 The prevalence of common mental disorders in the UK military33

Diagnosis

Prevalence (%)

Post-traumatic stress disorder

4.8

Any common mental health disorder

13.5

Any depressive syndrome

11

Any anxiety syndrome

4.5

Panic syndrome

1.1

Other anxiety syndrome

3.8

Somatisation disorder (a chronic condition in which there are numerous physical complaints that can last for years, and result in substantial impairment; the physical symptoms have a psychological cause and no underlying physical problem can be identified)

1.8

4.2.5 Deprivation

Deprivation can include social exclusion, unemployment (or lack of engagement in meaningful activities), under-employment, low income, homelessness and housing problems.

There is a correlation between household income and the prevalence of common mental health disorders in both men and women. Figure 7 shows that, as household income rises, the prevalence of common mental health disorders generally falls for both men and women.

Figure 7 Common mental health disorders by household income and gender21,32

Around half of people with common mental health disorders recover within 18 months. Disorders are more likely to persist in people in lower socioeconomic groups such as people who are on low incomes, long-term sick or unemployed[28]. The Marmot report 'Fair society, healthy lives: a strategic review of health inequalities in England post-2010' showed that, among other factors, poor housing and unemployment increase the likelihood that people will experience mental health disorders and affect the course of any subsequent recovery. These factors vary across different sections of society, with the result that some groups suffer multiple disadvantages.

The review 'Improving access to psychological therapies: a review of the progress made by sites in the first roll-out year' showed that 78% of service-users at initial assessment were economically active and 54% were in full or part-time employment. Thirty per cent reported receiving some type of benefit[23]. Commissioners should ensure that their common mental health disorder services are accessible to both people who are economically active and people who are not in employment or who are retired.

4.2.6 Housing

It is commonly accepted that mental health disorders are much more common among homeless and vulnerably housed people than in the general population[31]. In many instances mental health disorders play a significant part in the circumstances that cause people to lose their accommodation. The mental health disorder may then be exacerbated by the stresses associated with being homeless, which in turn will make it even harder for the person to achieve stability in their housing.

Studies suggest that although the largest group of homeless people are white men, the proportion of homeless people with a mental health disorder who come from black and minority ethnic groups is disproportionate in relation to their proportion in the general population[32].

4.2.7 Refugees and asylum seekers

Refugees and asylum seekers are known to have high rates of mental health disorder, particularly depression and post-traumatic stress disorder[33]. Refugees and asylum seekers are also at risk of homelessness because of constraints on their ability to work or claim benefits[34].

4.2.8 Long-term conditions

There are clear links between physical and mental health and there are shared risk factors for physical and mental illnesses. People with physical illnesses frequently present with both psychological and physical symptoms; and being physically ill, particularly chronic illness and disability, often negatively affects mental health.

People with two or more long-term conditions, such as cardiovascular disease or diabetes, are seven times more likely to have comorbid depression than those without long-term conditions[35]. Depression has been associated with a four-fold increase in the risk of heart disease, even when other factors are controlled for[36].

There is also evidence that people with mental health problems smoke much more than the rest of the population, consuming 42% of all cigarettes smoked in England[37]. This increases their risk of developing chronic physical health problems, such as chronic obstructive pulmonary disease (COPD), which in turn increases their risk of developing depression or anxiety. Studies show that a significant proportion of people with COPD have depression or anxiety[38].

4.2.9 Lesbian, gay, bisexual and transgender people

Information about the mental health of lesbian, gay, bisexual and transgender people is not collected at national level.

However, the available evidence suggests that lesbian, gay, bisexual and transgender people are at higher risk than heterosexual people of suicidal feelings, self-harm, drug or alcohol misuse and mental health disorders such as depression and anxiety. The reasons for these findings are complex and not yet fully understood. However, poor mental health in lesbian, gay, bisexual and transgender people has often been linked to experiences of homophobic discrimination and bullying.

A recent study conducted by researchers in London and Leicester found that mental health disorders are more common in gay, lesbian and bisexual people than heterosexual people[39].The study found that 4.1% of gay, lesbian and bisexual people had a depressive episode during the previous week compared with 2.1% of heterosexual people. Commissioners in areas with higher than average proportions of lesbian, gay, bisexual and transgender people may need to consider additional capacity and tailor services to meet the needs of this group.

4.2.10 Regional and local variation

All of the factors explored in section 4.2 vary geographically, meaning that some communities will have a significantly higher or lower than average prevalence of common mental health disorders. This will affect the service capacity needed. Figure 8 shows the variation across England for common mental health disorders[40]. The highest prevalence for men is in the East of England strategic health authority and for women the highest prevalence is in the North East strategic health authority.

Figure 8 Prevalence of common mental health disorders, by strategic health authority and gender (age standardised)27

4.3 Assessing existing local practice and determining optimum service capacity

Optimum service levels for people with common mental health disorders should be determined locally, and informed by a local needs assessment (see section 4.1) and local demography (see section 4.2).

The Department of Health's 'Talking therapies: a four year plan of action'[41] considers that full roll-out of the Improving Access to Psychosocial Therapies (IAPT) programme will have been achieved when an estimated 15% of people with common mental health disorders can access psychological interventions locally[42]. In England this would equate to around 1 million people receiving treatment each year (15% of the 7.2 million people aged 18 years or older with a common mental health disorder, see section 4.1).

For the purposes of this benchmark, it is assumed that low-intensity interventions are provided at step 2 in the stepped-care model, and high-intensity interventions are provided at step 3. The proportion of people receiving treatment at steps 2 and 3 varies locally depending on need and the availability of commissioned psychological intervention services.

'Talking therapies: a four year plan of action' estimates that two-thirds of people with common mental health disorders have mild mental health disorders and so need low-intensity treatment at step 2. One-third have moderate or severe mental health disorders and so need higher intensity treatment at step 3. However, a review of the progress made by sites in the first year of IAPT roll out in England showed that services differed greatly in the proportion of sessions delivered by low-intensity workers (Agenda for Change grades 1 to 5) and high-intensity therapists (Agenda for Change grades 6 and above). The median pattern was 45% low intensity (step 2) to 55% high intensity(step 3). This data suggests that there may be a lack of capacity in low intensity services, or that robust outcomes measurement data is not routinely collected by these services.

Table 6 and figure 9 show an estimate of the proportion of people who may enter each step of care. The model is based on the expert opinion of the Topic Advisory Group and other reviewed data[23],[43],[44]. Commissioners should use these estimates in table 6 and figure 9 to facilitate local discussion on optimum service levels.

It should be noted that a significant number of people may step up or step down and receive more than one type of treatment. This is examined in 'Enhancing recovery rates in IAPT services: lessons from analysis of the year one data'[23].

Table 6 Estimated proportion of the prevalent population who will enter each step

Step of care

Percentage of prevalent population

Step 0 (Not identified or not seeking treatment)

More than 60%

Step 1 (Identification, advice or referral, watchful waiting)

Up to 20%a

Step 2 (Low-intensity psychological interventions )

9%b

Step 3 (High-intensity psychological interventions)

6%b

Step 4 and above (More complex needs)

Less than 5%a

a Estimate based on the expert opinion of the Topic Advisory Group.

b It is assumed that 15% the prevalent population will be able to receive psychological treatment at steps 2 and 3 each year, in accordance with Department of Health (2011) 'Realising the benefits. IAPT at full roll-out', and that of these 60% will receive treatment at step 2 and 40% at step 3.

Figure 9 Estimated proportion of the prevalent population with common mental health disorders who will enter each step of care

4.4 Conclusion

Based on the epidemiological data and other information outlined above, table 7 summarises the 1-week prevalence rates for a range of common mental health disorders.

Table 7 1-week prevalence rates for common mental health disorders27

Condition

1-week prevalence rates

Generalised anxiety disorder

4.4%

Depressive episode (mild, moderate and severe)

2.3%

Phobias

1.4%

Obsessive compulsive disorder

1.1%

Panic disorder

1.1%

Mixed anxiety and depressive disorder

9%

Post-traumatic stress disorder

3%

The population benchmark for the number of people with a common mental health disorder is 17.7%, or 1770 per 100,000 population aged 18 or older. It is assumed that 50% of people with post-traumatic stress disorder will also have another common mental health disorder.

Table 8 summarises the likely proportion of people at each step of the pathway.

Table 8 Estimated proportion of the prevalent population who will enter each step

Step of care

Percentage of prevalent population

Step 0 (Not identified or not seeking treatment)

More than 60%

Step 1 (Identification, advice or referral, watchful waiting)

Up to 20%a

Step 2 (Low-intensity psychological interventions )

9%b

Step 3 (High-intensity psychological interventions)

6%b

Step 4 and above (More complex needs)

Less than 5%a

a Estimate based on the expert opinion of the Topic Advisory Group.

b It is assumed that 15% the prevalent population will be able to receive psychological treatment at steps 2 and 3 each year, in accordance with Department of Health (2011) 'Realising the benefits. IAPT at full roll-out', and that of these 60% will receive treatment at step 2 and 40% at step 3.

Commissioners should use their local needs assessment to determine optimum levels for local service provision. Commissioners should note that the benchmark rates do not represent NICE's view of desirable, or maximum or minimum, service levels.

Commissioners should use this benchmark and local data to facilitate local discussion on optimum service levels. There is considerable variation in the prevalence and identification of common mental health disorders. This is influenced by the social, economic and demographic profile of the local population. Therefore commissioners are encouraged to consider local assumptions.

Use the common mental health disorders commissioning and benchmarking tool to determine the level of service that might be needed locally and to calculate the cost of commissioning the service using the indicative benchmark and/or your own local data.



[16] McManus S, Meltzer H, Brugha T et al. (2009) Adult psychiatric morbidity in England, 2007. Results of a household survey. Leeds:The NHS Information Centre for health and social care

[17] The APMS defines a common mental health disorder as one or more of the following conditions: generalised anxiety disorder, depressive episode (mild moderate and severe), phobias, obsessive and compulsive disorder (OCD) and panic disorder.

[18] Kessler RC, Sonnega A, Bromet E et al.(1995) Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry 52: 1048–60

[19] CMHDs as defined in APMS as one or more of the following conditions: generalised anxiety disorder, depressive episode (mild moderate and severe), phobias, obsessive and compulsive disorder and panic disorder plus 50% of post traumatic stress disorder (see section 4.1.1)

[20] Scott KM, Von Korff M, Alonso J (2008) Age patterns in the prevalence of DSM-IV depressive/anxiety disorders with and without physical comorbidity. Psychological Medicine. 38: 1659–69

[21] Streiner DL, Cairney J, Veldhuizen S (2006) The epidemiology of psychological problems in the elderly. Canadian Journal of Psychiatry 52: 185–91

[22] Glover G, Webb M, Evison F (2010) Improving access to psychological therapies. A review of the progress made by sites in the first roll-out year. Stockton‐on‐Tees: North East Public Health Observatory

[23] Jacoby R and Oppenheimer C (2002) Psychiatry in the elderly Oxford: Oxford University Press

[24] CMHDs is here defined as one or more of the following conditions: generalised anxiety disorder, depressive episode (mild, moderate or severe), phobias, obsessive compulsive disorder and panic disorder, plus a proportion of post-traumatic stress disorder (see section 3.1.1).

[25] McManus S, Meltzer H, Brugha T et al. (2009) Adult psychiatric morbidity in England, 2007. Results of a household survey.The NHS Information Centre for health and social care: Leeds

[26] HM Prison Service (2011) Mental health primary care in prison [online]. Available from www.prisonmentalhealth.org/about_this_site.html

[27] Singleton N, Meltzer R, Gatward J et al. (1998) Psychiatric morbidity among prisoners in England and Wales. London: Office for National Statistics,

[28] A person remanded in custody will be detained in a prison until a trial or sentencing hearing takes place. The majority of prisoners on remand have not been convicted of a criminal offence and are awaiting trial following a not guilty plea.

[29] 'Sentenced' is used here to mean those sentenced to a term of imprisonment after conviction.

[30] Iversen AC, van Staden L, Hacker Hughes J et al. (2009) The prevalence of common mental disorders and PTSD in the UK military: using data from a clinical interview-based study. BMC Psychiatry 9: 68

[31] Rees S (2009) Mental ill health in the adult single homeless population: a review of the literature. London: Crisis

[32] Austin EL, Andersen R and Gelberg L (2008) Ethnic differences in the correlates of mental distress among homeless women. Women's Health Issues 18: 26–34

[33] Ryan DA, Benson CA and Dooley BA (2008) Psychological distress and the asylum process: a longitudinal study of forced migrants in Ireland. Journal of Nervous and Mental Disease 196: 37–45

[34] Palmer D (2006) Imperfect prescription: Mental health perceptions, experiences and challenges faced by the Somali community in the London Borough of Camden and service responses to them. Primary Care Mental Health 4: 45–56

[35] Moussavi S, Chatterji S, Verdes E et al.(2007) Depression, chronic disease and decrements in health: results from the World Health Surveys. Lancet 370: 851–8

[36] Osborn DPJ, Levy G, Nazareth I et al. (2007) Relative risk of cardiovascular and cancer mortality in people with severe mental illness from the United Kingdom's general practice research database. Archives of General Psychiatry 64: 242–9. Available from http://archpsyc.ama-assn.org/cgi/content/abstract/64/2/242

[37] McManus S, Meltzer H, Campion J Cigarette smoking and mental health in England. Data from the Adult Psychiatric Morbidity Survey. National Centre for Social Research, 2010

[38] Department of Health (2011) An outcomes strategy for chronic obstructive pulmonary disease (COPD) and asthma in England. London: Department of Health

[39] Chakraborty A, McManus S, Brugha TS et al. (2011) Mental health of the non-heterosexual population of England. British Journal of Psychiatry 198: 143–8. Available from http://bjp.rcpsych.org/content/198/2/143.abstract

[40] Common mental health disorders here uses the same definition as in APMS (see section 3.1.1).

[41] Department of Health (2011) Impact assessment. Talking therapies: a four year plan of action. London: Department of Health

[42] Department of Health (2010) Realising the benefits. IAPT at full roll out. London: Department of Health

[43] Department of Health (2011) Impact assessment. Talking therapies: a four year plan of action. London: Department of Health

[44] Data (unpublished) from the East of England region shows that 60% of people who completed treatment in 2010/11 had low-intensity treatments and 40% had high-intensity treatments (this includes people who stepped up or down within the pathway).