Improving Access to Psychological Therapies (IAPT), an NHS England service providing talking therapies, is meeting its target recovery rate of 50%. However, engagement in treatment, as well as recovery rates, may be lower for some groups.

To assess variation in treatment completion and recovery rates by demographic and socioeconomic group and to describe rates of further referrals for patients to IAPT and secondary mental health services.

Using 121 548 administrative records for 2019–2020 and 2022–2023 for the Norfolk and Waveney area, we estimated associations of age, gender, ethnicity and deprivation with the likelihood of treatment completion and recovery using logistic regression modelling. We also described rates of further referrals.

Younger people and those living in deprived areas were less likely to recover or complete treatment, with those aged 16–17 years (n = 735) having the lowest adjusted odds for recovery (adjusted odds ratio = 0.5, 95% CI: 0.5–0.6) compared with those aged 36–70 years, and those aged 18–24 years (n = 23 563) having the lowest rate of completion (adjusted odds ratio = 0.5, 95% CI: 0.5–0.6). Further referrals before April 2022 were recorded for 45.4% of 6513 patients who had completed treatment and 68.8% of 9469 who had not completed treatment, and for 39.4% of 2007 recovered patients in 2019–2020 and 53.1% of 1586 who had not recovered. Non-completers had relatively more further referrals to secondary mental health services compared with completers (43.6% v. 22.8%; P < 0.01).

Younger people and those living in deprived areas have lower recovery and completion rates. Those who have completed treatment and not recovered have higher rates of further referrals.

It is now accepted that social factors affect not only onset but also mental health treatment outcomes. One such factor is financial difficulty. Within National Health Service (NHS) Talking Therapies, problem debt has been shown to interfere significantly with recovery from mental health problems, estimated as 22% versus 50% recovered with no problem debt. One solution is a combined money advice and psychological therapy intervention to improve treatment outcomes.

The aim of the current study was to trial a combined money advice and psychological therapy service within NHS Talking Therapies, to ascertain its feasibility and acceptability.

This study employed a mixed methods case series of individuals attending high-intensity cognitive–behavioural treatment who were provided with a combined intervention (money advice service plus NHS Talking Therapies). Acceptability and feasibility were evaluated through interviews, and benefit was assessed from comparisons of routinely collected symptom measures and compared to historical recovery estimates.

Some 32 participants, with similar gender distribution but more representation from ethnic minorities, were recruited from NHS Talking Therapies. One-third demonstrated complete recovery on both depression and anxiety, while half showed symptom improvement and modest improvements on the financial outcomes measure. Our interviews with patients, therapists and money advisors suggested the combined intervention was acceptable and beneficial, but that money worries should be identified earlier.

The combined service is acceptable, accessible and could deliver benefit, even in the short term, to those with mental health and debt problems.

People at high risk for psychosis access primary care mental health services for depression and anxiety and are unlikely to recover from these affective symptoms. We report the first controlled trial of cognitive–behavioural therapy (CBT) for depression and anxiety, minimally adapted for psychosis risk, in primary care.

To evaluate feasibility, acceptability and signals of efficacy for CBT for depression and anxiety adapted for psychosis risk, designed in collaboration with people with psychosis.

A longitudinal controlled trial comparing best practice CBT for depression and anxiety (CBT-BP) with CBT adapted for psychosis risk (CBT-PR), in patients meeting criteria for UK primary care services and who are also clinically high risk for psychosis (trial registration no. ISRCTN40678).

Rates of recruitment (55 to CBT-BP, 44 to CBT-PR), completion of measures (90% CBT-BP, 94% CBT-PR) and retention in therapy (75% CBT-BP, 95% CBT-PR) demonstrate the feasibility and acceptability of the adapted therapy. Routine measures of depression and anxiety signal improved clinical and recovery outcomes for CBT-PR. Psychosis and relational measures signal sustained improvement (at 3 months) in the CBT-PR group. No serious adverse events were reported.

Primary care mental health services present a unique opportunity to identify and treat people at risk of psychosis at a time when they are help-seeking. CBT for depression and anxiety, minimally adapted for psychosis risk, can be delivered in routine services, and is likely to improve clinical and recovery outcomes and reduce psychosis risk. A definitive trial is needed to estimate clinical and cost-effectiveness.

Older adults are under-represented in Talking Therapies (previously named IAPT) services in the UK, a national priority for improvement in the NHS. A Talking Therapies service in the south of England identified that many older adults who were referred did not opt-in to assessment. We aimed to explore the characteristics of these older adults and understand their experiences, to inform recommendations to support them to opt-in to the service in future. First, demographic and referral characteristics were compared for older adults who did and did not opt-in, to explore any that increased odds of not opting-in. Next, surveys and semi-structured interviews were used to investigate older adults’ reasons for not opting-in. Responses were thematically analysed, and themes were categorised using the COM-B model to inform theory-based recommendations. Older age, being from an ethnic minority group, having a previous referral, not being able to receive text messages, and not self-referring (e.g. being referred by GP) all significantly increased the chances of older adults not opting-in. Thematic analysis found that impersonal and confusing processes, as well as older adults’ limited knowledge of Talking Therapies, beliefs about therapy, and physical, cognitive and life changes with age were barriers to opting-in. Several recommendations are made, including ideas to increase accessibility of information, change procedures to improve personal connection, and explore and overcome practical barriers. Improving routine data and feedback collection from people who do not opt-in will be important to inform and evaluate improvements.

1. (1) To recognise that the ongoing issue of under-representation of older adults within Talking Therapies extends beyond barriers to referral.

2. (2) To understand demographic and referral characteristics that may increase the likelihood of older adults not opting-in to a Talking Therapies service following referral.

3. (3) To understand the experiences of older adults who do not opt-in and the barriers they cite, exploring factors that impacted their capability, opportunity and motivation to opt-in.

4. (4) To consider how services could change their procedures, information sharing, and community outreach to better serve older adults.

Since 2008, the Improving Access to Psychological Therapies (IAPT) programme has offered adults in England evidence-based psychological treatments for common mental disorders (CMDs) such as depression and anxiety disorders. However, inequalities in access have not been explored at the national level.

Using a unique individual patient dataset that linked 2011 Census information of English residents to national IAPT data collected between April 2017 and March 2018, we estimated the rate of access by a wide range of socio-demographic characteristics that are not routinely available. A large household survey was used to estimate the prevalence of probable CMDs by these socio-demographic characteristics. We estimated the probability of access to IAPT amongst people with CMDs by comparing the rates of access from IAPT data and the estimates of prevalence of CMDs from the household survey. Both unadjusted and adjusted (for important patient characteristics) access rates were estimated in logistic regression models.

As a proportion of those with a probable CMD, access to IAPT varied markedly by socio-demographic characteristics. Older adults, males, people born outside of the UK, people with religious beliefs, people from Asian ethnic backgrounds, people reporting a disability and those without any academic or professional qualifications were underrepresented in IAPT services nationally, in adjusted models.

The identification of patients who may be underrepresented in IAPT provides an opportunity for services to target outreach and engagement with these groups. Further understanding of barriers to access should help increase equity in access.