Older adults are under-represented in Talking Therapies (previously named IAPT) services in the UK, a national priority for improvement in the NHS. A Talking Therapies service in the south of England identified that many older adults who were referred did not opt-in to assessment. We aimed to explore the characteristics of these older adults and understand their experiences, to inform recommendations to support them to opt-in to the service in future. First, demographic and referral characteristics were compared for older adults who did and did not opt-in, to explore any that increased odds of not opting-in. Next, surveys and semi-structured interviews were used to investigate older adults’ reasons for not opting-in. Responses were thematically analysed, and themes were categorised using the COM-B model to inform theory-based recommendations. Older age, being from an ethnic minority group, having a previous referral, not being able to receive text messages, and not self-referring (e.g. being referred by GP) all significantly increased the chances of older adults not opting-in. Thematic analysis found that impersonal and confusing processes, as well as older adults’ limited knowledge of Talking Therapies, beliefs about therapy, and physical, cognitive and life changes with age were barriers to opting-in. Several recommendations are made, including ideas to increase accessibility of information, change procedures to improve personal connection, and explore and overcome practical barriers. Improving routine data and feedback collection from people who do not opt-in will be important to inform and evaluate improvements.

1. (1) To recognise that the ongoing issue of under-representation of older adults within Talking Therapies extends beyond barriers to referral.

2. (2) To understand demographic and referral characteristics that may increase the likelihood of older adults not opting-in to a Talking Therapies service following referral.

3. (3) To understand the experiences of older adults who do not opt-in and the barriers they cite, exploring factors that impacted their capability, opportunity and motivation to opt-in.

4. (4) To consider how services could change their procedures, information sharing, and community outreach to better serve older adults.

Since 2008, the Improving Access to Psychological Therapies (IAPT) programme has offered adults in England evidence-based psychological treatments for common mental disorders (CMDs) such as depression and anxiety disorders. However, inequalities in access have not been explored at the national level.

Using a unique individual patient dataset that linked 2011 Census information of English residents to national IAPT data collected between April 2017 and March 2018, we estimated the rate of access by a wide range of socio-demographic characteristics that are not routinely available. A large household survey was used to estimate the prevalence of probable CMDs by these socio-demographic characteristics. We estimated the probability of access to IAPT amongst people with CMDs by comparing the rates of access from IAPT data and the estimates of prevalence of CMDs from the household survey. Both unadjusted and adjusted (for important patient characteristics) access rates were estimated in logistic regression models.

As a proportion of those with a probable CMD, access to IAPT varied markedly by socio-demographic characteristics. Older adults, males, people born outside of the UK, people with religious beliefs, people from Asian ethnic backgrounds, people reporting a disability and those without any academic or professional qualifications were underrepresented in IAPT services nationally, in adjusted models.

The identification of patients who may be underrepresented in IAPT provides an opportunity for services to target outreach and engagement with these groups. Further understanding of barriers to access should help increase equity in access.