Unfortunately, accessing Cognitive Behavioral Therapy (CBT) is not as easy as picking up a prescription from your local pharmacy. The lack of trained staff, the stigma of diagnosis and treatment, and the specific needs of each service user are just some of the barriers (Gask et al., 2012; Harvey & Gumport, 2015).

So, what is CBT? CBT is a psychological intervention, preferred by many patients over pharmacological interventions (Layard et al., 2007). It is in the form of talk therapy and helps people develop skills to understand and change their negative thoughts and beliefs (Layard et al., 2007). It also works great on anxiety disorders (Layard et al., 2007).

Let’s talk about anxiety disorders. As the article mentions, anxiety disorders are common mental health conditions and cause intense feelings of fear and avoidance. They can be effectively treated with pharmacological and psychological interventions, plus various other approaches. Whilst both of the main approaches (medication and talking) work, psychological interventions have a longer-lasting result and prevent relapse better (Layard et al., 2007).

This review explores ways in which access to CBT for anxiety disorders can be improved. There is one special detail about this study. It explores any strategy reported to improve access, even if that was not the purpose of its application.

Methods

A scoping review was conducted based on the research question: What strategies can be used to improve access to CBT for anxiety disorders?

The search was done on Medline, Embase, CINAHL, and PsychINFO using the search engines Scopus, PubMed, and EBSCOhost. They searched for anxiety disorders, CBT interventions, and improving access by combining various related keywords from each category. The search, however, excluded PTSD and OCD as they are not diagnosed anymore as subcategories of anxiety disorders.

The inclusion criteria were assessed by calculating the level of agreement between researchers (or otherwise the inter-rater reliability) and refined to achieve almost perfect agreement. The initial selection of articles was done by looking through 1,739 abstracts, followed by selecting and reviewing 126 full-text articles and narrowing them down to 73 for the analysis. The analysis was done by identifying emerging themes from each study, that relate to the research aim.

Results

The researchers identified six categories of strategies to improve access to CBT for anxiety disorders.

Contributing to the evidence-base

• In environments where care is provided, it seems important to indicate how applicable and effective CBT treatment is.
• It is important to learn from current strategies and programs by keeping up to date with any evaluations and improvements on how they are implemented.
• The authors encourage more research on specific access-related issues and on ways to detect early who is less likely to engage in treatment.

Identifying CBT delivery modalities to adopt in practice

• Remote treatment through telephone, video, or chat might be the answer when the barrier to access is personal such as stigma or lack of resources nearby.
• Low-intensity CBT, including group therapy and self-guided treatment through books or online, is one way to improve access without needing more therapists.
• A Transdiagnostic CBT (tCBT) approach helps with this as well, since practitioners undertake one type of training but can work with patients that have a large variety of symptoms.

Building capacity for CBT delivery

• A way to increase the number of providers is to reduce the cost of training and train non-psychotherapist staff to deliver basic CBT.
• Supporting the providers through supervision, feedback and online learning tools are some ways to make sure CBT always has an evidence-based delivery.

Attuning the process of access to local needs

• It is important to consider the local population and adjust the cost, the payment methods, and the availability for self-referral accordingly.
• The path to access EBPTs can be confusing, so knowing a step-by-step process can encourage people to engage with the services.
• Services need to make sure there is good communication between primary care providers and specialist care clinicians.

Engaging potential service users

• Awareness campaigns can spread valuable information to encourage anyone sceptical about seeking help.
• Through education, we can tackle misinformation about CBT and confront stigmas around mental health services, encouraging more people to engage.

Improving programs and policies

• Policies can improve access by establishing access-oriented standards that must be met throughout the mental healthcare system.
• The authors point out the benefits of programs that can be adjusted to many people’s needs, such as Improving Access to Psychological Therapies (IAPT) and Better Access.

Conclusions

Overall, this research brings to light many ways in which access can be improved. However, as the authors mention, it is important to keep in mind that the process of improving access is not a “one size fits all” approach. Instead, programs that aim to improve access should carefully consider their target audience and combine a variety of complementary strategies. In conclusion, the authors talk about practice guidelines. They suggest that each category of healthcare providers would benefit from specific guidelines on improving access to CBT through their specific roles.

Strengths and limitations

Strengths of this study include it being the first to come up with the practical implementation of strategies that can improve access to CBT for anxiety disorders. Of the 1,739 studies that were reviewed, 74 were included with strong agreement among the researchers on the inclusion criteria which strengthens the validity of the study.

One of the main strengths of the study is how flexible and expanded the inclusion criteria are. The authors analysed articles with any strategies reported to improve access, even if the strategies were not explicitly developed for CBT, anxiety disorders, and improving access. This allowed for a variety of original strategies and suggestions that can be helpful in improving access to come up.

However, it is important to look at some of the study’s exclusion criteria as they limit the applicability of the findings. Firstly, they excluded research with strategies specifically designed for mental health services in low- or middle-income countries. Already most evidence-based strategies for mental health disorders have been developed in high-income countries (Fendt-Newlin et al., 2019). Excluding these articles neglects the fact that low and middle-income countries have an increased need for better access to treatments as well as the need for extended intervention to achieve a treatment outcome (Hook et al., 2021; Finegan et al., 2019). This exclusion not only limits the generalisation of the findings in many countries but also avoids considering strategies that could overcome barriers specific to low-income populations in high-income countries.

On top of that, the study does not mention any cultural, ethnic, or spiritual/religious diversity in the studies which limits the generalisation of the results. Considering that the articles reviewed were either in English or French, we can assume there was not much ethnic diversity in the chosen articles.

Implications for practice

The idea of providing information comes up in a few results, and it seems like a good first step to conquer in practice. To do so, GP practices may consider handing out leaflets and posters that include three critical pieces of information: What CBT is, why and how it works, and a series of steps to access CBT through their practice. Based on the results, this information can be handy in engaging people who do not know about CBT or are hesitant to try it.

What about the people waiting to access CBT? The solution here seems to be transdiagnostic CBT (tCBT), as mentioned in Identifying CBT delivery modalities to adopt in practice and earlier research (Norton & Roberge, 2017). It has great results on a variety of anxiety disorders, including comorbid anxiety disorders; it required only one type of training and, therefore, can accommodate lots of people with a variety of symptoms (Norton & Roberge, 2017). However, we must not forget that individual barriers exist beyond the application of tCBT, and it’s essential always to consider the context when developing and applying interventions (Rosso Buckton, 2015).

Providing CBT digitally can accommodate many people quickly. It seems particularly beneficial for people with less severe mental health issues that enjoy the feeling of control over their health (Borghouts et al., 2021). However, all contextual factors can “make it or break it” when engaging with digital mental health interventions (Borghouts et al., 2021).

An important issue is therapy being too expensive for most people. As the study suggests, policies need to encourage more private insurance companies to cover CBT. This would alleviate the congestion in public mental health services. The costs to adequately train in EBPTs is also very expensive, and a way to build capacity for CBT delivery is by lowering the training costs, which can be encouraged by policy development.

This research provides a great foundation for similar research to be replicated and identify strategies to improve access in specific populations. Some suggestions for specific populations that would benefit from this research are international students and neurodivergent students. A disproportionately large number of international students seem to experience mental health issues, with anxiety being one of the most common (Cheung et al., 2020; Auerbach et al., 2018). On top of that, more than half of all students diagnosed with ADHD across 24 universities worldwide had at least one comorbid mental health disorder, and anxiety was among the two most prevalent (Mak et al., 2021).

Statement of interest

None.

King’s MSc in Mental Health Studies

This blog has been written by a student on the Mental Health Studies MSc at King’s College London. A full list of blogs by King’s MSc students from can be found here, and you can follow the Mental Health Studies MSc team on Twitter.

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Links

Primary paper

Carrier J.-D, Gallagher F, Vanasse A. et al (2022). Strategies to improve access to cognitive behavioral therapies for anxiety disorders: A scoping review. PLOS ONE, 17(3), e0264368.

Other references

Auerbach R. P, Mortier P, Bruffaerts R. et al (2018) WHO World Mental Health Surveys International College Student Project: Prevalence and distribution of mental disorders. Journal of Abnormal Psychology, 127(7), 623–638.

Borghouts J, Eikey E, Mark G. et al (2021) Barriers to and Facilitators of User Engagement With Digital Mental Health Interventions: Systematic Review. Journal of Medical Internet Research, 23(3).

Cheung K, Tam K. Y, Tsang H. et al (2020) Depression, anxiety and stress in different subgroups of first-year university students from 4-year cohort data. Journal of Affective Disorders, 274, 305–314.

Fendt-Newlin M, Jagannathan A, Webber M. (2019) Cultural adaptation framework of social interventions in mental health: Evidence-based case studies from low- and middle-income countries. International Journal of Social Psychiatry, 66(1).

Finegan M, Firth N, Delgadillo J. (2019) Adverse impact of neighbourhood socioeconomic deprivation on psychological treatment outcomes: the role of area-level income and crime (PDF). Psychotherapy Research, 30(4), 1–9.

Gask L, Bower P, Lamb J. et al (2012) Improving access to psychosocial interventions for common mental health problems in the United Kingdom: narrative review and development of a conceptual model for complex interventions. BMC Health

Harvey A. G, Gumport N. B. (2015) Evidence-based psychological treatments for mental disorders: Modifiable barriers to access and possible solutions. Behaviour Research and Therapy, 68(6), 1–12.

Hook K, Ametaj A, Cheng Y. et al (2021) Psychotherapy in a resource-constrained setting: Understanding context for adapting and integrating a brief psychological intervention into primary care. Psychotherapy, 58(4), 557–575.

Layard R, Clark D, Knapp M. et al (2007) Cost-benefit analysis of psychological therapy. National Institute Economic Review, 202, 90–98. [SAGE journals abstract]

Mak A. D. P, Lee S, Sampson N. A. (2021) ADHD Comorbidity Structure and Impairment: Results of the WHO World Mental Health Surveys International College Student Project (WMH-ICS). Journal of Attention Disorders, 26(8). [PubMed abstract]

Rosso Buckton A. (2015). Conversations between anthropology and psychiatry: drawing out the best from interdisciplinarity in global mental health. Australas Psychiatry, 23(6), 3–5.

Norton P. J, Roberge P. (2017) Transdiagnostic Therapy. Psychiatric Clinics of North America, 40(4), 675–687.

Photo credits

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