We have all seen the same news headline: rates of mental health problems are on the rise, especially for anxiety and depression, and particularly among young people. One proposed solution to this public health issue is to increase access to psychological services, where first-line treatments such as Cognitive Behavioural Therapy (CBT) can be delivered to those who need it.
However, some research suggests that even if these services are accessed, younger people may have poorer outcomes from psychological therapies than adults who are aged 25 years and older. The difficulty is that this research is conflicting – some research finds a significant association between age and treatment outcomes, whereas other papers do not (Barry et al., 2018; Buckman et al., 2021). Additionally, the samples that are used in clinical research are not necessarily representative of those who receive treatment; the average age of participants in clinical trials for anxiety and depression is typically 44 years old, whereas the average age of adults treated in psychological services is 32 years old.
This means that there is a discrepancy between research and practice, and a gap in our knowledge as to whether psychological treatments for depression and anxiety are as effective in young adults as working age adults. Using real-world data from 1.5 million adults in England, Saunders and colleagues (2025) undertook a study to help address this.
Are treatment outcomes for anxiety and depression worse for young adults compared to working age adults? Saunders et al. (2025) used data from 1.5 million adults in England to investigate.
Methods
The authors used data from adults aged 16-65 years old who had accessed NHS Talking Therapies Services (NHSTT; previously known as Improving Access to Psychological Therapies [IAPT]) and received a course of treatment for anxiety or depression from April 1st 2015 to March 31st 2019. Records were excluded if the patient was still accessing treatment; did not score above thresholds for clinically significant anxiety or depression at initial assessment; had missing age data at referral; did not provide more than one outcome measure; or did not receive 2+ treatment sessions.
Primary outcomes included change in depression severity scores (measured on the Patient Health Questionnaire 9-item [PHQ-9]) and anxiety severity scores (Generalised Anxiety Disorder Scale 7-item [GAD-7]). Secondary outcomes included recovery, reliable recovery, reliable improvement, and reliable deterioration. Data was analysed using regression models.
Individuals with lived experience of accessing NHSTT were involved in the design, analysis, and interpretation of the study findings.
Results
Sample characteristics
Out of 2.1 million records, data was analysed from 309,758 young adults aged 16-24 (mean age = 20.8 years, SD = 2.3) compared against 1,290,130 working age adults aged 25-65 (mean age = 41.5 years, SD = 11.1). Most participants were female (young adults: 69.4%; working age adults: 65.2%) and White (young adults: 82.5%; working age adults: 83.6%). In comparison to working age adults, young adults were:
- More likely to live in socially deprived areas
- More likely to be neurodivergent
- Less likely to report being disabled or long-term sick
- Less likely to be prescribed psychotropic medication
- More likely to be treated for Obsessive Compulsive Disorder (OCD), social phobia, or other phobic or panic-related disorders.
Young adults had lower anxiety and depression scores pre-treatment and a higher mean amount of session non-attendance (where the service is not informed). Working age adults were more likely to formally cancel sessions with the service.
Main findings
As the age of participants increased, so did the change in depression and anxiety scores from pre- to post-treatment.
For depression, the mean change in PHQ-9 scores increased from 5.5 (95% CI [5.4 to 5.6]) at age 20 to 6.3 (95% CI [6.2 to 6.3]) at age 35, and from 6.9 (95% CI [6.8 to 7]) at age 55 to 7 (95% CI [6.9 to 7.1]) at age 60.
For anxiety, the mean change in GAD-7 scores increased from 5.1 (95% CI [5.0 to 5.1]) at age 20 to 6.2 (95% CI [6.1 to 6.2]) at age 60 and remained stable at 6 (95% CI 5.9 to 6.1]) between ages of 35 and 55 years.
For both depression and anxiety, young adults reported a smaller change in symptom scores from the beginning to end of treatment, even when accounting for differences in demographic characteristics and treatments.
Furthermore, young adults had a significantly lower odds of reliable recovery and were more likely to report reliable deterioration in symptoms than working adults. The authors estimated that if outcomes for young adults were similar to working age adults, over 23,000 more young adults would have achieved reliable recovery across the four-year study period.
For both depression and anxiety, routinely delivered psychological treatments appear to work better for adults aged 25 years and older in comparison to young adults aged 16-24 years.
Conclusions
In sum, outcomes were poorer for young adults than working age adults after receiving psychological interventions for depression and anxiety, highlighting a concerning discrepancy in the effectiveness of routinely delivered treatments between age groups.
The authors suggest numerous potential explanations for why this could be, including underlying aetiological differences linked with greater severity, the impact of developmental milestones and periods of transition, and different levels of service engagement.
However, the key takeaway from this paper is that something needs to change in how we deliver mental health care to young adults in England.
If outcomes between young adults and working age adults were similar, Sanders et al. (2025) estimate that over 23,000 more young adults would have achieved reliable recovery over the 4-year study period.
Strengths and limitations
Strengths
- Data: These findings are based on data from a national sample of 1.2 million working age adults and >300,000 young adults. Not only does this increase the likelihood of the sample being representative of the population of England and therefore more generalisable, but such a large sample increases the statistical power of the study and the subsequent reliability of the findings. Confidence is further increased by the robustness of the findings in light of adjustments and sensitivity analyses, suggesting the observed effects are accurate.
- Outcomes: Using both routinely collected outcome measures (i.e., PHQ-9 and GAD-7) as well as service-level outcomes (i.e., reliable improvement) allows for both symptom change and clinically meaningful change to be assessed. This is important because it translates statistical significance into real-world impact, which can be more intuitive for readers and stakeholders (e.g., policymakers, clients, clinicians) to understand.
- Stakeholder involvement: Individuals with lived experience of using NHSTT were involved in the study design, analysis, and interpretation of the findings. This helps to ensure the relevance of the findings and service-level implications (although it’s unclear how much, as the authors do not elaborate on who was involved or exactly what this involvement looked like, reducing transparency and our ability to determine how genuine the involvement was).
Limitations
- Data: These findings are based on routinely recorded data, meaning that many measures of interest are not included, and potential confounders may not be accounted for. This reduces the reliability of the findings, as we cannot be certain that the observed effects are not due to an unaccounted factor.
- Broad age ranges: Both comparator groups have broad age ranges, and it is not clear what the impact of the categorisation of ‘young adult’ versus ‘working age adult’ is. Is it appropriate to assume that data from a 16-year-old undertaking their exams is similar to data provided by a 22-year-old who has just finished university and started their first graduate job? Equally, is it appropriate to assume that data from a 30-year-old who is starting a family is similar to data from a 65-year-old who has just retired? The authors do not seem to consider this within their limitations.
- Pre-COVID context: While not a substantial limitation, it is worth considering that this data was collected pre-pandemic, and that how services operate across England have undergone significant changes. As the authors acknowledge, use of videoconferencing for treatments is on the rise, which could impact engagement, yet the current study cannot address this. For me, though, this is more representative of a broader issue within research: the delay between undertaking a study and publishing the findings, and the further delay to implementing findings in practice.
These findings are based on data from a national sample of 1.5 million individuals, increasing the power of the study and its reliability. However, only using routinely collected data means that many potential confounders are not considered.
Implications for practice
The findings from this large-scale retrospective cohort study highlight that young adults experience smaller improvements after receiving routinely delivered psychological therapies than working age adults, indicating that changes are urgently needed. There are clear implications for clinicians, policymakers, and researchers.
Clinicians working within NHSTT should reflect on their current approach to delivering treatments to young adults and consider whether they are witnessing the changes they anticipate. While the current study cannot explain why young adults seem to benefit less from these treatments, engaging with wider research could highlight potential strategies to increase engagement and responsiveness. For some clients, this may mean increasing the flexibility of sessions, paying greater attention to the developmental context, or integrating digital technologies. For example, Becky Appleton summarised a trial by Mason et al. (2023) that found a text-based CBT intervention was effective at reducing depression in young adults, with a large effect. Updating service-level training protocols and making sure that youth-specific supervision is regularly available for those working with young adults might also be beneficial.
Policymakers should consider whether the current structure and approach of NHSTT are meeting the needs of young adults, and what adaptations may be needed to ensure that these services and treatments are resulting in reliable improvements. Ensuring that young adults are getting timely access to effective, engaging treatments that address developmentally-relevant concerns seems key, but these kinds of changes will not work without adequate funding and infrastructure.
Researchers should work to build on these findings, investigating potential underlying mechanisms that help to explain why young adults may not respond to these treatments as well as working age adults. Once potential factors are identified, we can then begin to explore treatment adaptations and other changes that may result in reducing this gap in improvement.
Policymakers need to review whether the current structure and approach within NHS Talking Therapies are adequately meeting the needs of young adults, or whether changes are needed to improve outcomes.
Statement of interests
None.
Links
Primary paper
Saunders, R., Suh, J. W., Buckman, J. E., John, A., El Baou, C., Pilling, S., … & Stringaris, A. (2025). Effectiveness of psychological interventions for young adults versus working age adults: a retrospective cohort study in a national psychological treatment programme in England. The Lancet Psychiatry, 12(9), 650-659. https://doi.org/10.1016/S2215-0366(25)00207-X
Other references
Appleton, B. (2024). SMS CBT TLC CYP? 🤔 Does delivering cognitive behavioural therapy via text messages help improve depression in young people?. The Mental Elf.
Barry, T. J., Yeung, S. P., & Lau, J. Y. (2018). Meta-analysis of the influence of age on symptom change following cognitive-behavioural treatment for anxiety disorders. Journal of Adolescence, 68, 232-241. https://doi.org/10.1016/j.adolescence.2018.08.008
Buckman, J. E., Saunders, R., Stott, J., Arundell, L. L., O’Driscoll, C., Davies, M. R., … & Pilling, S. (2021). Role of age, gender and marital status in prognosis for adults with depression: An individual patient data meta-analysis. Epidemiology and Psychiatric Sciences, 30, e42. https://doi.org/10.1017/S2045796021000342
Mason, M. J., Coatsworth, J. D., Zaharakis, N., Russell, M., Brown, A., & McKinstry, S. (2023). Testing mechanisms of change for text message–delivered cognitive behavioral therapy: randomized clinical trial for young adult depression. JMIR mHealth and uHealth, 11, e45186. https://doi.org/10.2196/45186