According to Richard Layard, professor of economics at the London School of Economics and leading ‘happiness guru’, the provision of a range of talking therapies through a network of ‘psychological treatment centres’ can contribute to a substantial reduction in the £7.2 billion invalidity benefit budget.1 Layard's initiative is the latest manifestation of the ‘happiness agenda’ now being enthusiastically embraced by both government and opposition politicians and a range of academic authorities. Ministers believe that of the 2.7 million people claiming invalidity benefits, more than 1 million (some 40% of the total), who suffer from a range of mental health problems, are likely to be susceptible to therapeutic intervention by 10 000 specially-recruited cognitive behavioural therapists, working in 250 high street drop-in centres.
Although we are not lucky enough to have such a centre in our immediate locality in Hackney, colleagues in the neighbouring borough of Newham, have been favoured with a pilot project launched earlier this summer.2 ‘Collective happiness is what it strives for’ and local GPs are being encouraged to refer unhappy patients, who can also ‘simply turn up and get help’. The figures sound enticing. Layard's Depression Report provides an example of 100 people given therapy for a 16-week period. It calculates that half of this group will lose their symptoms within that time and, since each course of treatment costs £750, and the combined cost of a month's incapacity benefit and lost taxes is £750 the treatment offers a very rapid payback. Furthermore, there are additional savings: less spending on drugs and reduced demand on GP services.3 Everyone a winner!
We can be confident that Layard's centres will soon fall victim to the fallacy named in honour of his distinguished predecessor at the LSE, William Beveridge. In his eponymous 1942 report that proposed a national health service as part of the post-war welfare state, Beveridge anticipated that ‘the development of health and rehabilitation services would lead to a reduction in the number of cases requiring them’.4 In common with other pioneers of the health service, Beveridge believed that improvements in health resulting from better health services would rapidly result in a reduced demand for health and welfare services and hence in a declining burden on the exchequer. Of course, it soon became apparent that the costs of the health service continued to rise inexorably, creating the pressures to curtail costs that have been a focus of recurrent controversy ever since. In 1961, Enoch Powell, then health minister in a Conservative government, referred to Beveridge's expectation of declining costs as ‘a miscalculation of sublime dimensions’. Yet the Beveridge fallacy continues to overshadow health policy half a century later.
There are a number of reasons why Layard's happiness centres are even less likely than Beveridge's plans to achieve the goal of curtailing welfare spending, let alone that of making people happier. While proclaiming the latest estimate of the prevalence of mental illness (‘one in six’) the Depression Report never asks why it is that the diagnosis of psychiatric conditions as a cause of long-term incapacity has increased by a factor of more than three over the past two decades. The reinterpretation — by patients as well as by doctors — of a widening range of adverse life experiences and existential difficulties in terms of psychiatric disorders (from depression and anxiety to post-traumatic stress disorder and social phobia) is clearly a major factor in the rising tide of disability attributed to mental illness. The provision of more therapeutic services is more likely to increase the scale of disability than reduce it.
Professor Layard and his government sponsors make extravagant claims for the efficacy of cognitive behavioural therapy, based on extrapolating from a number of small studies to the entire population. The notion that a few weeks of CBT will transform miserable people languishing in idleness and dependency — at a rate of 50% — into happy shiny productive workers is embarrassing in its absurdity.
- © British Journal of General Practice, 2006.
