28 November 2016 November 2016 29 Expert guide: Psychology 2016 Timely access to effective and efficient services is an important component of successfully re-solving mental health problems. A large amount of evidence has been accumulated through Randomised Controlled Trials (RCTs) regard-ing the efficacy of various treatments but very little research effort has been directed towards establishing what the ideal treatment protocol should be. Given the disparity between the re-search context of an RCT and the clinical set-tings in which treatments are delivered trans-lating the findings from research to practice has not been straightforward. RCTs of psychological treatments typically use manualised treatments which are delivered ac-cording to regular, standardised time frames. These time frames are established a priori by the researcher or research team prior to the conduct of the study. For example, some re-searchers might develop a 12 session treatment protocol of cognitive behaviour therapy (CBT) which is to be delivered weekly over a three month period. In routine clinical practice, how-ever, patients typically vary in their attendance patterns. The numbers missed of and cancelled appointments which are costly to services are strong evidence of the fact that patients make their own decisions about when to attend even ment A is more efficacious than 12 sessions of Treatment B is not a demonstration that 12 ses-sions of treatment A is required for satisfactory outcomes. Clearly, designing treatments to be longer than what most patients require is inef-ficient and may contribute to compromised ac-cess to services. An extended program of research that began in rural Scotland and has continued in remote Australia has investigated a patient-led model if that is different to what the therapist has rec-ommended.Furthermore, patients accessing psychological treatment in clinical rather than research set-tings, do not attend the number of appoint-ments that manualised treatments are designed to provide. There is in fact a substantial dis-connect between the number of sessions treat-ments are designed to be and the number of ap-pointments patients attend. Typically research-ers design treatments to be greater than ten ses-sions whereas patients typically attend between four and six sessions on average. Guidelines for treatment also recommend lengths of treatment that far exceed what most patients require. The NICE guidelines for the treatment of depres-sion, for example, recommend that if people are receiving CBT they should receive 16 to 20 sessions over a three to four month period. It is the case, however, that very few patients ever attend that many sessions and yet they still ex-perience benefits from the treatment. It is seldom recognised that the evidence pro-vided by RCTs is evidence of what can be ef-fective but not evidence of what is necessary for effective outcomes. For example, demon-strating with an RCT that 12 sessions of Treat-of service delivery. In this approach, systems are established so that patients, rather than cli-nicians, determine when and how many ses-sions of psychological treatment will be sched-uled. Patients make appointments to see a psychological therapist in much the same way they would make an appointment to see a GP. Patients are able to attend as often as they need to for as long as they need to within the con-straints of the service context. Professor Timothy A. Carey +61 8 8951 4700 www.crh.org.au Improving Access to Psychological Treatment with Patient-Led Appointment Scheduling By Professor Timothy A. Carey Australia