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

5.3 Specifying step 3 services for people with moderate to severe common mental health disorders

Commissioning services at step 3, underpinned by NICE guidance and quality standards, is likely to contribute to achieving the following service outcomes:

  • Reducing the stigma and discrimination associated with a diagnosis of, or treatment for, common mental health disorders.

  • Increasing the proportion of people who are identified, assessed and receive treatment in accordance with NICE guidance.

  • Improving the proportion of people who make a clinically significant improvement or recover.

  • Reducing the proportion of people who relapse.

  • Identifying risk and preventing avoidable harm.

  • Improving emotional wellbeing, quality of life and functional ability in people with common mental health disorders.

  • Preventing sick leave and maintaining people in education, employment or meaningful activities.

  • Reducing long-term unemployment, homelessness and family breakdown.

  • Improving service-user choice and experience of mental health services.

  • Improving the interface between services for people with common mental health disorders.

Table 12 summarises step 3 of the stepped-care model for common mental health disorders.

Table 12 Step 3 services

Focus of the intervention

Nature of the intervention

Depression: persistent subthreshold depressive symptoms or mild to moderate depression that has not responded to a low-intensity intervention; initial presentation of moderate or severe depression

  • Antidepressants

  • Behavioural activation

  • Behavioural couples therapy

  • CBT

  • Collaborative care (for people with depression and a chronic physical health condition)

  • Combined interventions

  • Counselling (for people who decline an antidepressant, CBT, IPT, behavioural activation or behavioural couples therapy)

  • IPT

  • Self-help groups

  • Short-term psychodynamic psychotherapy (for people who decline an antidepressant, CBT, IPT, behavioural activation or behavioural couples therapy)

Generalised anxiety disorder: with marked functional impairment or that has not responded to a low-intensity intervention

  • Applied relaxation

  • CBT

  • Combined interventions

  • Drug treatment

  • Self-help groups

Obsessive-compulsive disorder: with moderate or severe functional impairment

  • Antidepressants

  • CBT (including ERP)

  • Combined interventions and case management

  • Self-help groups

Panic disorder: moderate to severe panic disorder

  • Antidepressants

  • Bibliotherapy based on CBT principles

  • CBT

  • Self-help groups

Post-traumatic stress disorder

  • Drug treatment EMDR

  • Trauma-focused CBT

All disorders

  • Befriending

  • Educational and employment support services

  • Referral for further assessment and interventions

  • Rehabilitation programmes

  • Support groups

Abbreviations: CBT, cognitive behavioural therapy; EMDR, eye movement desensitisation and reprocessing; ERP, exposure and response prevention; IPT, interpersonal psychotherapy.

The key service components when commissioning effective services at step 3 are:

  • high intensity psychological interventions (see section 5.3.1)

  • pharmacological interventions (see section 5.3.2)

  • additional support services (see section 5.3.3)

Note that although there are some similarities in the key components of step 2 and 3 services there are significant differences in the costs of commissioning these services, which are clearly demonstrated in the commissioning and benchmarking tool.

5.3.1 High intensity psychological interventions

Table 13 summarises the high-intensity psychological interventions recommended by NICE for each common mental health disorder at step 3.

Table 13 High-intensity psychological interventions at step 3

Psychological intervention

Disorder

Applied relaxation

  • Generalised anxiety disorder

Behavioural activation

  • Depression

Behavioural couples therapy

  • Depression

Bibliotherapy based on cognitive behavioural therapy principles

  • Panic disorder

Cognitive behavioural therapy (CBT)

  • Depression

  • Generalised anxiety disorder

  • Panic disorder

Cognitive behavioural therapy including exposure and response prevention

  • Obsessive-compulsive disorder

Cognitive behavioural therapy (trauma-focused)

  • Post-traumatic stress disorder

Counselling

  • Depression (for people who decline an antidepressant, cognitive behavioural therapy, interpersonal psychotherapy, behavioural activation or behavioural couples therapy)

Eye movement desensitising and reprocessing

  • Post-traumatic stress disorder

Interpersonal psychotherapy

  • Depression

Self-help groups

  • Depression

  • Generalised anxiety disorder

  • Panic disorder

  • Obsessive-compulsive disorder

Short-term psychodynamic psychotherapy

  • Depression (for people who decline an antidepressant, cognitive behavioural therapy, interpersonal psychotherapy, behavioural activation or behavioural couples therapy)

Combined interventions

  • Depression

  • Generalised anxiety disorder

  • Obsessive-compulsive disorder

Commissioners should use their local needs assessment (see section 4) to estimate the number of people likely to be offered and to accept high-intensity psychological interventions at step 3. They should ensure that they commission a range of high-intensity psychological interventions that meet the needs of the whole population and enable people to make an informed choice of evidence-based interventions.

Commissioners should have plans to work towards commissioning adequate levels of all of the high-intensity psychological interventions recommended by NICE. Commissioners may wish to begin by commissioning, and improving capacity within:

  • CBT services and self-help groups; these are recommended for the largest number of disorders

  • interpersonal therapy, behavioural activation and behavioural couples therapy; these are recommended for depression and generalised anxiety disorder, which are the most prevalent conditions.

Nationally there is a shortage of trained staff to provide all psychological interventions, but in particular interpersonal therapy and behavioural activation. Commissioners should work closely with their regional IAPT workforce commissioners and local providers to identify resources for ongoing workforce training and development, to improve access to psychological interventions for which there is a local shortage.

Commissioners should ensure that their providers of high-intensity psychological interventions can demonstrate cost effectiveness and high quality. In addition to unit costs, service user outcomes and cost-per-outcome commissioners should consider the following indicators:

  • Quality assurance: commissioners should ensure providers are meeting, or working towards meeting, the quality measures specified in the contract and NICE quality standards. They should ensure that providers follow NICE guidance on delivering high-intensity psychological interventions, including offering service users the recommended length, number and frequency of sessions (including additional sessions for follow-up and relapse prevention if indicated).

  • Use of validated tools: commissioners should ask providers to demonstrate that they use evidence-based assessment, monitoring and outcomes tools (such as the IAPT data standard, see section 3.3). Providers should also be able to demonstrate that psychological interventions are provided using competence frameworks or structured models developed from evidence-based treatment manuals.

  • Accessibility: commissioners should specify that services are accessible, for example providing services outside normal working hours, delivering interventions or assessments in a person's home and in accessible venues, and using appropriate technology (see section 3.5.1).

  • Workforce competencies: commissioners should specify that providers' staff:

    • are trained to deliver any psychological therapies that they provide

    • receive ongoing programmes of workforce/personal development, which may include the management of more complex cases such as people with common comorbidities

    • receive regular supervision from a person competent in both supervision and the intervention.

  • Unit cost: per service-user and per outcome. See commissioning and benchmarking tool.

Commissioners may wish to refer to the Guidance for Commissioning IAPT training 2011/12 to 2014/15 for further information about workforce development and training. Staff who deliver psychological interventions at step 3 are commonly referred to as high-intensity therapy workers. Commissioners should ensure that they commission adequate local capacity each year for high-intensity psychological therapy training.

Recommendation 1.5.1.4 of 'Depression in adults' (NICE clinical guideline 90) states:

'For people with depression who decline an antidepressant, CBT, IPT, behavioral activation or behavioural couples therapy, consider:

  • counselling for people with persistent subthreshold depressive symptoms or mild to moderate depression

  • short-term psychodynamic therapy for people with mild to moderate depression.

Discuss with the person the uncertainty of the effectiveness of counselling and psychodynamic psychotherapy in treating depression.'

The expert clinical opinion of the Topic Advisory Group is that a large number of people are inappropriately offered counselling for the management of common mental health disorders, having not previously been offered and declined psychological interventions or antidepressants. Therefore commissioners and their partners should:

  • Actively monitor the local use of counselling services for depression and other common mental health disorders.

  • Explore the reasons behind any inappropriate use of counselling services, such as lack of:

    • availability of first-line psychological interventions

    • knowledge of the high intensity psychological interventions recommended by NICE, or

    • knowledge on how to make appropriate referrals.

    These points should be covered by awareness-raising training (see section 5.1.1). Commissioners should make GPs and other professionals who make referrals aware of any inappropriate use of counselling and discuss alternatives with them.

  • Ensure that service-user information explains the evidence base behind first-line psychological interventions (see service models in section 5.5).

  • Work with local counselling services to ensure that both counselling and psychological intervention services are used appropriately and to enable cross-referral of people who may be inappropriately referred for counselling or psychological interventions.

  • Consider making training available for counsellors to deliver psychological interventions such as cognitive behavioural therapy or interpersonal psychotherapy.

Counselling is often provided by a counsellor contracted to a GP surgery, so commissioners should consider opportunities to provide regular psychological intervention sessions in GP surgeries.

5.3.2 Pharmacological interventions

Commissioners should be aware of NICE's recommendations on the use of antidepressants and other medication to manage common mental health disorders. Note that medication is usually recommended in combination with psychological interventions and may be considered for relapse prevention.

At around £6 per person per month[48], antidepressants are not considered to be high cost drugs. However because of the high volume of prescribing, they are one of the top 30 British National Formulary sections by overall cost and number of items[49].

Commissioners and their partners should ensure that their local care pathways include a regular medication review for all service-users taking medication for common mental health disorders. This may help to prevent inappropriate prescribing and ensure that alternative interventions or medication, or referral, are considered for people whose condition is not responding to their current medication, and to ensure that people whose condition has sufficiently improved cease treatment or are stepped down in a planned and timely manner.

Commissioners may wish to involve psychiatrists or GPs with a special interest in common mental health disorders in pharmacological intervention pathways. The clinicians may provide support to healthcare professionals who are prescribing for people with comorbidities or more treatment-resistant conditions, and assist with risk management.

To ensure appropriate prescribing of medication, commissioners should monitor the volume and cost of primary care prescribing of antidepressants and other medication that is, and is not, recommended by NICE for managing common mental health disorders at step 3. Commissioners should use this information to:

  • Ensure that antidepressants and other drugs are prescribed in accordance with NICE recommendations, paying particular attention to the offer and uptake of combination psychological interventions, and the timeliness and frequency of medication reviews.

  • Work with their medicines management team and prescribers to ensure that prescribers are using the cheapest suitable drug.

  • Ensure that prescribers are aware of when to prescribe antidepressants in combination with or instead of psychological interventions (see also section 5.1.1).

5.3.3 Additional support services

NICE recommends a range of additional support services for people with common mental health disorders. These include:

  • education and employment support services – steps 2 and 3; these may be provided by local job centres or occupational health/therapy departments

  • support groups – steps 2 and 3; these are typically provided by not-for-profit organisations

  • befriending – step 3; these are typically provided by not-for-profit organisations

  • rehabilitation programmes – step 3.

Common mental health disorders rarely occur in isolation from wider social circumstances, and can have a considerable impact on them. Commissioning additional support services can reduce isolation, improve confidence and manage some of the underlying stresses that can increase the risk of common mental health disorders.

Commissioners should ensure that their pathway identifies a range of additional support services for people with common mental health disorders, including those listed above. In addition, commissioners may also wish to develop relationships with services that provide advice on debt or welfare, and with victim support services.

Commissioners should ensure that any additional support services use referral and outcomes monitoring tools that are integrated with the other providers in the pathway.


[48] Average cost based on six common selective serotonin reuptake inhibitors, see the cost impact and commissioning assessment for the NICE quality standard 'Depression in adults'.

[49] NHS Information Centre for health and social care (2011) Top 30 BNF sections by cost in 2010–11. Items spreadsheet [online]. Available from http://www.ic.nhs.uk/