A 48-year-old woman with rheumatoid arthritis and depression was referred to an Improving Access to Psychological Therapies (IAPT) service in Birmingham in 2021. According to a complaint filed with the Parliamentary and Health Service Ombudsman, she waited eight weeks for an assessment. When the therapist learned of her arthritis, she was told that chronic pain was not within the service's remit. The sessions focused on generic anxiety-reduction techniques that assumed she could attend exercise classes and leave the house at will. After missing two appointments due to flare-ups, she was discharged. No one contacted her GP or rheumatology team. This pattern is documented in NHS complaints data and internal reviews.

IAPT, the National Health Service's flagship mental health programme in England, treats roughly 1.2 million people each year for anxiety and depression. Its stated aim is to deliver evidence-based therapies within a stepped-care model. But a growing body of evidence, including a 2023 analysis by the Nuffield Trust, shows that the programme's design and its primary performance target systematically exclude people with long-term physical health conditions (LTCs) such as diabetes, chronic obstructive pulmonary disease (COPD), arthritis, and heart disease. The Nuffield Trust analysis found that patients with LTCs are 20 percent less likely to complete treatment than those without.

When Depression Treatment Ignores Chronic Pain

The IAPT pathway was built for mild-to-moderate anxiety and depression. Its clinical manuals separate mental and physical health into distinct silos. Therapists are trained to treat mood disorders, not to understand how chronic pain interacts with depression. Patients with LTCs are often told, as the woman with rheumatoid arthritis was, that their physical symptoms fall outside the service's scope. This is not an isolated anecdote; it reflects a structural limitation embedded in the programme's design.

A 2019 study in the British Journal of Psychiatry by Smith et al. analysed data from over 50,000 IAPT patients and found that recovery rates for people with LTCs were roughly 10 percentage points lower than those without. The authors noted that standard IAPT treatment protocols did not address the specific interactions between physical symptoms and mental health, such as how pain can reduce motivation to engage in behavioural activation exercises. The NHS manual for IAPT makes only passing reference to LTCs. The core training for psychological wellbeing practitioners (PWPs) and high-intensity therapists includes no mandatory module on chronic illness. As a result, clinicians often lack the confidence or knowledge to adapt interventions for patients whose physical condition limits their ability to attend appointments, complete homework, or participate in exposure exercises. Patients report feeling invalidated when their pain is dismissed as a barrier rather than integrated into the therapy.

The consequence is a high dropout rate among this group. An analysis by the Centre for Mental Health in 2020 estimated that roughly 30 to 40 percent of patients with LTCs who are referred to IAPT do not complete treatment, compared with around 20 percent for those without LTCs. The reasons are multifaceted: inflexible appointment systems, lack of home-based options, and therapists who do not understand the fluctuating nature of chronic conditions. The system blames the patient for non-attendance, but the fault lies in a design that fails to accommodate their reality.

The IAPT Recovery Target That Skews Care

At the heart of the problem is the primary metric by which IAPT services are judged: the proportion of patients who move from above a clinical threshold for anxiety or depression to below it. This is calculated using the Patient Health Questionnaire-9 (PHQ-9) for depression and the Generalised Anxiety Disorder-7 (GAD-7) for anxiety. A patient is considered to have recovered if their score drops below a fixed cut-off point. The national target is that at least 50 percent of patients who complete treatment achieve this.

Patients with LTCs often have lower baseline scores on these measures because their depression is driven more by functional impairment than by standard cognitive symptoms. They may not endorse every item on the PHQ-9, but their quality of life is severely affected. Their room to shift below the cut-off is smaller. This creates a perverse incentive for IAPT services to prioritise patients who are more likely to show a large numerical improvement, typically those with less complex needs and no physical comorbidity.

Internal NHS data from 2022, obtained by the mental health charity Mind under a Freedom of Information request, showed that recovery rates for patients with LTCs were around 38 percent, compared with 53 percent for those without. This gap of roughly 15 percentage points has persisted for years. Commissioners, who are responsible for funding local IAPT services, are judged on their ability to meet the 50 percent target. The rational response for a service under financial pressure is to accept referrals from people who are likely to recover quickly and to discourage or delay those who are not.

This is not a hypothetical distortion. A 2018 audit by the Royal College of Psychiatrists found that some IAPT services were actively triaging patients with LTCs into lower-priority waiting lists or suggesting they seek help elsewhere. The report quoted one service manager as saying that patients with complex physical conditions were 'not a good fit' for the programme. The target, intended to drive quality, has instead driven exclusion. The NHS has acknowledged the issue in principle but has not changed the metric.

What the Evidence Says About Integrated Mental–Physical Care

There is no shortage of evidence that integrating mental health support into the management of LTCs improves outcomes. The COINCIDE trial, published in The Lancet Psychiatry in 2016, randomised patients with diabetes and depression to either usual care or a collaborative care model in which a mental health practitioner worked alongside the GP and diabetes nurse. The intervention group showed significantly greater improvement in depression scores and better diabetes self-management at 12 months.

A systematic review by the Cochrane Collaboration in 2021 examined 77 randomised trials of collaborative care for depression in people with LTCs. It found that integrated models produced moderate improvements in depression outcomes and small but significant improvements in physical health measures such as blood pressure and glycaemic control. The review concluded that the effect sizes were comparable to those seen in IAPT for patients without LTCs, and that the approach was cost-effective over the long term.

NICE guidelines for depression in adults with chronic physical health problems recommend stepped care that includes collaborative care, problem-solving therapy, and behavioural activation adapted for physical limitations. Yet implementation has been patchy. A 2023 survey by the British Psychological Society found that fewer than 15 percent of IAPT services had formal protocols for adapting therapy for patients with LTCs, and fewer than 10 percent had dedicated care pathways for this group. The guidelines exist on paper but are not enforced.

The evidence also shows that patients value this integration. Qualitative studies consistently report that people with LTCs want their mental health care to be connected to their physical health care. They do not want to have to choose between seeing a therapist who does not understand their condition and a doctor who does not have time to talk about mood. When services are integrated, adherence to both mental and physical treatment plans improves. The question is not whether integration works, but why the NHS has not made it a priority.

How Patients Fall Through the Cracks

Consider the case of a 55-year-old woman with type 2 diabetes and depression. Her GP referred her to IAPT after she scored moderately on the PHQ-9. She was offered a telephone assessment, which she took during a work break. The assessor asked standard questions about sleep, appetite, and mood but did not ask about her diabetes management or how her blood sugar fluctuations affected her energy. She was placed on a six-week wait for low-intensity cognitive behavioural therapy (CBT).

When the therapy began, the therapist recommended a schedule of daily walks and activity scheduling. The woman explained that her blood sugar dropped unpredictably and that she could not walk without carrying snacks and testing her glucose. The therapist had no experience with diabetes and suggested she 'just try it'. After two sessions, the woman stopped attending. She felt that the therapy was not designed for her. She was discharged and not referred back to her GP. Her depression worsened, and her diabetes control deteriorated. This is a composite case, but it reflects patterns documented in NHS complaints data.

An estimated 4.6 million people in England have both a long-term physical condition and a mental health problem, according to the King's Fund. Of these, roughly one in three report that their mental health needs are not met. IAPT is the primary public mental health service for adults with common mental disorders, yet it is failing this group. The reasons are not malicious; they are structural. The programme was designed for a different population, and its targets reinforce the exclusion.

The result is a cycle of repeated referrals, failed treatments, and declining health. Patients with LTCs are more likely to be re-referred to IAPT within two years than those without, but they are no more likely to recover. They are also more likely to end up in secondary care mental health services, which are more expensive and less accessible. The cost of this failure is borne not only by patients but by the NHS budget as a whole. A 2022 report by the London School of Economics estimated that untreated depression in people with LTCs costs the NHS roughly £8 billion per year in increased physical health care use and lost productivity.

Pilot Programmes That Show a Way Forward

Between 2018 and 2022, NHS England funded pilot programmes known as LTC-IAPT in 12 clinical commissioning group (CCG) areas. These pilots adapted standard IAPT protocols for patients with specific LTCs, including diabetes, COPD, and chronic pain. The adaptations included longer session times, pain management modules, and closer collaboration with physical health teams. Therapists received additional training on the psychological impact of chronic illness and how to modify behavioural activation for patients with limited mobility.

The results were promising. Recovery rates in the LTC-IAPT pilots matched the general IAPT average of around 50 percent, despite the pilots serving a more complex patient group. Patient satisfaction scores were high, and dropout rates were lower than in standard IAPT. The pilots demonstrated that with modest adjustments, the same therapy model could work for people with LTCs. The additional cost per patient was estimated at roughly £200, which is small compared with the savings from reduced hospital admissions and improved medication adherence.

Yet the pilots were not scaled. The funding for the evaluation ended in 2022, and the NHS did not commission a national rollout. The NHS Long Term Plan, published in 2019, mentions the need to integrate mental and physical health care, but it does not set specific targets for IAPT to address LTCs. Without a target, there is no accountability. The pilots remain a proof of concept that has not been turned into policy. NHS England says it is 'considering the findings', but no timeline has been given.

The contrast with other countries is instructive. In Australia, the Better Access initiative includes provisions for patients with chronic physical conditions to access longer sessions. In the Netherlands, collaborative care for depression in diabetes is standard practice and reimbursed by insurers. The UK's IAPT programme was once a world leader in expanding access to psychological therapies, but it has not evolved to meet the needs of an ageing population with multiple comorbidities. The pilots show that the tools exist; what is missing is the political will to implement them.

What Needs to Change in the Next Contract

The current IAPT contract, which governs how services are commissioned and paid for, expires in 2027. That deadline represents an opportunity to redesign the programme. Mental health campaigners and professional bodies have proposed several changes. The most important is to replace the single binary recovery target with a stratified measure that accounts for comorbidity burden. A patient with diabetes and depression who improves by five points on the PHQ-9 but remains above the cut-off should not be counted as a failure if that improvement translates into better diabetes control.

A second change is to require collaboration between IAPT services and physical health teams. This could take the form of joint clinics, shared care plans, or mandatory liaison with GPs and specialists. The existing IT systems in the NHS make data sharing difficult, but pilot sites showed that it is feasible with modest investment. The LTC-IAPT pilots also demonstrated the value of having a named link worker who coordinates care across the divide.

Third, all IAPT staff should receive mandatory training in the overlap between LTCs and mental health. This includes understanding how symptoms of depression can mimic or exacerbate physical symptoms, how chronic pain alters cognitive patterns, and how to adapt therapy for patients who cannot attend weekly appointments. The training is not expensive; it can be delivered online and integrated into existing supervision structures. Some services have already developed such modules, but they are not standardised or mandated.

Without these changes, the targets will continue to exclude the sickest patients. The NHS has a choice: it can keep measuring what is easy to measure, or it can start measuring what matters. The evidence is clear that integrated care works. The pilots have shown that adaptation is feasible. The patients are waiting. The next contract is the moment to act.

For further reading, see our related articles: NHS Mental Health Targets: A Broader Critique and Integrated Care Models for Chronic Conditions.