‘Intensive Care PTSD’

this was the banner  headline on the BBC News today, January 13th 2021. It followed the announcement of a study by Prof Neil Greenberg, which revealed that staff had been ‘traumatised’ by the first wave of the pandemic. This in turn led for Paul Farmer Chief executive of MIND to call for ‘the right support at the right time’ on BBC radio 4 today. The Government has promised an extra £15 million so that extra support can be given.  But what sort of support?

In the press release accompanying publication of his study in the journal Occupational Medicine, Professor Greenberg notes ‘Further work is needed to better understand the real level of clinical need amongst ICU staff as self-report questionnaires can overestimate the rate of clinically relevant mental health symptoms’. His study was based on a web survey of ICU staff about half of whom responded, about half whom met the ‘threshold’ for PTSD, severe anxiety or problem drinking. There is a clear need to go beyond self-report measures.

I am currently writing a book ‘Personalising Trauma Treatment: reframing and reimagining’ to be published by Routledge. In this work I suggest that the initial conversation with trauma victims   should include ‘Gateway Diagnostic Interview Questions’ , with regard to Covid an appropriate subset would be:

Depression (evidence that at least one of the answers to the following questions is in the affirmative)

1. During the past month have you often been bothered by feeling, depressed or hopeless?

2. During the past month have you often been bothered by little interest or pleasure in doing things?

 

Panic Disorder

1. Do you have unexpected panic attacks, a sudden rush of intense fear or anxiety?

2. Do you avoid situations in which the panic attacks might occur?

 

Post-traumatic Stress Disorder

In your life, have you ever had any experience that was so frightening, horrible or upsetting that, in the past month, you

1. Have had nightmares about it or thought about it when you did not want to?

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

3. Were constantly on guard, watchful, or easily startled?

4. Felt numb or detached from others, activities, or your surroundings?

5. Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the events may have caused?

Evidence that at least three of the answers to the symptom questions above are in the affirmative

Alcohol Dependence (evidence is that the response to the first three of the following questions is in the affirmative)

1. Have you felt you should cut down on your alcohol/drug?

2. Have people got annoyed with you about your drinking/drug taking?

3. Have you felt guilty about your drinking/drug use?

4. Do you drink/use drugs before midday?

Asking GDIQ questions encourages the person to furnish possible examples of the impact of the symptom on their life, so that they feel listened to. Reference can then be made to other  diagnostic symptoms for the particular disorder, to tease out whether there are sufficient impairing symptoms for that disorder, to merit that diagnostic label.  Use of GDIQ’s is part of a conversation, it is not a rapid fire interrogation or checklist. As a supplement to the GDIQ people can be asked whether this is something that they want help with, as they might not want to verbalise that they want to sort the problem out themselves, but are too polite to express this. 

The NICE recommended treatments are diagnosis specific, thus there is a recommendation of trauma focussed CBT for PTSD. But those traumatised by Covid are likely to find it toxic to be pushed to describe in graphic detail the horrors encountered. In my book I argue that this is unnecessary, rather that what is of key importance is to assess what the person takes their memory of being in ICU means about today. It is not the event that causes PTSD but the mental time travel to the worse period and the significance given to it  for today. This approach  is much less challenging for whoever is  accompanying the effected medical staff and family/friends who have seen horrors.

 

Dr Mike Scott

Unnecessary Treatment Is The Rule In IAPT – Due Diligence?

 

The UK Government, Improving Access to Psychological Therapies (IAP) only uses psychometric test screening measures  to assess clients, most commonly the  PHQ9 ( a measure of the severity of depression) and GAD7 (a measure of the severity of generalised anxiety disorder), but other measures are advised for other disorders, such as the PCL-5 for PTSD. A study by Zimmerman and Matia (2001) [The Psychiatric Diagnostic Screening Questionnaire: development, reliability and validity. Comprehensive psychiatry, 42(3), 175–189. https://doi.org/10.1053/comp.2001.23126 ] showed that questionnaire measures that reflect DSM criteria have a roughly 90% sensitivity across major depressive disorder, PTSD, panic disorder, social phobia and GAD, i.e it correctly identifies 9 out of 10 of those who do have one of these disorders. But it identifies only about 60% (specificity) of those who do not have the disorder and for GAD only 50%.  However many more people do not have a particular disorder than have one, leading to unnecessary treatment for many. The National Audit Office should take note of this and re-instate its’ investigation, where is the due diligence with regards to IAPT? £4billion has been given to IAPT!

Depression

In the Zimmerman  and Mattia (2001) study 47.9% of the psychiatric outpatients had major depression. Assuming psychiatric outpatients are a reasonable approximation to the IAPT population, then in a sample of 100 patients approx. 50 would have depression and 50 would not. Of the 50 with depression, 45 would have been correctly identified and treated. However of the 50 who did not have depression only, 30 would have been correctly identified leaving 20 as false positives, candidates for inapropriate treatment. Thus roughly for every two depressed cases appropriately treated one would be inappropriately treated. For depression the appropriate/inappropriate ratio is 2/1 – pretty wasteful.

Generalised Anxiety Disorder

In the Zimmerman Mattia Study 17.5% pf the psychiatric outpatients  had GAD. Thus in a sample of 100 patients approx. 18 would have GAD, of whom 16 would have been correctly identified and treated. But 82 would not have GAD but 50% of them would have been regarded as having GAD meaning that 41 would have been inappropiately treated. Thus for GAD the appropriate/inappropriate ratio is 16/41, so that for every one GAD client treated appropriately 2-3 others are treated inappropriately.

Post-traumatic Stress Disorder

In the Zimmerman and Mattia study 10.5% of the psychiatric outpatients had PTSD. Thus in a sample of 100 clients approx. 11 would have PTSD with 9 being correctly classified and treated. However 89 would not have PTSD of these 62% (55) were correctly classified, meaning that 34 were false positives. Thus the ratio of appropriately treated/ inappropriately treated is approximately 1/4 , for every one treated appropriately 4 are treated inappropriately.

IAPT’s Preposterous Claim On Recovery

Given the ubiquity of unnecessary treatment in IAPT, its’ claim of a 50% recovery rate [IAPT Manual (2019)] is preposterous.  I found a 10% recovery rate Scott (2018) https://doi.org/10.1177%2F1359105318755264, which is much more likely if a body relies simply on a screening instrument.

The Need To Translate Research Methodology Into Routine Practice

Ehlers et al. Trials (2020) 21:355 https://doi.org/10.1186/s13063-020-4176-8 have used the PDSQ to screen for cases of PTSD in their study of therapist assisted treatment for the condition, but have followed the screen up by using a standardised semi-structured interview the SCID to then diagnose PTSD. In this study they have kept a screen in its place and not allowed it free rein as in IAPT.  The IAPT Manual p25 states ‘To ensure that all relevant problems are identified, it is recommended that assessments include systematic screening for each of the conditions that IAPT treats. Standardised commercial screening questionnaire that cover the full range of problems and that can be completed by people before they attend an assessment can be considered ‘ and cites the  PDSQ as an example. But sole use of any screening instrument is very wasteful.

Ehlers et al (2020) have sought to establish whether no more than 4 hours therapist time can make a real world difference to PTSD sufferers lives, a consummation devoutly to be wished, these authors could be well employed helping IAPT get its’ own house in order.

 

Dr Mike Scott

‘Psychometric Testing In Clinical Settings’ – contains a devastating critique of IAPT

this is the title of a Chapter, by Hamilton Fairfax in a book ‘Psychometric Testing’ edited by Barry Cripps in (2017) and published by John Wiley. Fairfax pulls no punches, on the over interpretation of a psychometric test score:

‘These concerns are increased when organisations place value on such scores, and base commissioning and service decisions on them away from the clinical context. Increasingly, such decisions by NHS and private health care providers are made by individuals who are either not familiar with the specifications of services or not sufficiently trained clinically or methodologically to understand the information they are provided with. Instead they are under pressure to ensure services are economically viable; the attraction of a number that purports to measure improvement is obvious. It is possible to manage mental health services in a way that would not be permissible in banking, the military or food production.

One risks accusations of arrogance or pomposity if one’s critique of a management decision is based on the manager’s lack of awareness or training. A strange and unintended consequence of EBP (evidence based practice) is that it provides a heuristic for the uninformed to speak with authority in a way in which many of us would not speak to a mechanic just because we had read a car manual. Stating that something is ‘evidence-based’, whether or not the person knows much about the area being discussed, is often seen as sufficient. It is dangerous to base policy and the survival of clinical services on this level of insight. In outlining this position I do not want to demonise managers or create an equally unhelpful heuristics. Many are well informed, with good clinical experience, but their roles have increasingly alienated them from the realities of practice. Demand and the pressure to be more effective can diminish flexibility and creative thinking, leading to a reliance on quick information such as numbers and ‘evidence’. I speak from personal experience and am aware that these pressures only increase with more responsibilities’.

Hopefully we can manage a better New Year

Dr Mike Scott

Questions NHS England and IAPT Have Ignored Over Covid

 

How do you distinguish an adaptive reaction to Covid from a maladaptive one? Without answering this fundamental question NHS England has offered guidance….https://www.yourcovidrecovery.nhs.uk/managing-the-effects/effects-on-your-mind/managing-fear-and-anxiety/. on how psychological debility associated with having Covid might be managed. They offer a range of cognitive behavioural strategies commonly employed in the management of anxiety and depression. In addition they invite the public to complete a quiz, https://www.nhs.uk/conditions/stress-anxiety-depression/mood-self-assessment/ that actually comprises the questions in the PHQ-9 (that measures the severity of depression) and the GAD-7 (that measures the severity of generalised anxiety disorder), together with a question on the extent to which they feel impaired by these difficulties.

If the person scores highly on the quiz they are advised to see their GP and/or refer themselves to IAPT, as a diagnosis can only be made by professionals. But the IAPT Manual states IAPT therapists don’t make diagnosis, further they have no expertise with regards to a physical disorder.What then would an IAPT therapist be treating?

How meaningfully can a GP determine whether the fatigue associated with Covid should count towards a diagnosis of depression? Should the low mood associated with being ill count as a depressive symptom? Many Covid patients have breathing difficulties that can disturb sleep, should this insomnia count as a depression symptom? Loss of appetite is a common symptom of being ill, should it count as a symptom of depression? Should the worries of a Covid patient about the trajectory of their illness and occupational/financial impairment count as a symptom of anxiety?  With the exception of helping patients with Covid who are suicidal, psychologising Covid patients symptoms looks like an exercise in empire building.  

Whilst NHS England’s offering of the CBT strategies to members of the public might not be unreasonable, there is no evidence that these strategies taken out of the context in which they were developed make a real-world difference to those with a long term condition. Equally there is no evidence that such strategies delivered by IAPT practitoners makes a real world difference, the service has a recovery rate of 10% Scott (2018) https://doi.org/10.1177/1359105318755264

Are we to assume that those most debilitated by Covid, the likely most stressed, are the most in need of psychological intervention?

What body of knowledge do psychological therapists have that would make a real-world difference to the outcome of Covid in a particular instance?

 

Dr Mike Scott

Following NICE Guidance On Covid Treatment Threatens To Overwhelm Mental Health Services

Yesterday NICE issued guidance on the management of Covid post 12 weeks (long term) https://www.nice.org.uk/guidance/ng188 and recommends that those with mild anxiety or mild depression are referred to mental health services, with severe cases of anxiety/depression referred to psychiatrists. IAPT (Improving Access to Psychological Therapies) has already been conducting webinars for its’ Step 3 staff, within which concerns were expressed about possibly overwhelming services and the pathologising of normality. Despite this further webinars are planned for the low intensity (Step 2) staff. Buoyed by its’ success in attracting monies for psychological therapies for long-term conditions (LTCs), such as chronic pain, irritable bowel syndrome, IAPT sees an opportunity to extend its’ reach to those affected by Covid. Those with long term Covid are likely to suffer the same fate of those with Chronic Fatigue Syndrome of not being really listened to. 

Given that according to NICE the most common features of long term Covid are fatigue, ‘brain fog’ and breathlessness, and that ‘symptoms of anxiety and depression’  are presented as possible symptoms of Covid at any stage, how is it possible to make an additional diagnosis of anxiety and depression? With the exception of the few, Covid patients who may be suicidal the distinction between the physical and psychological symptoms is fraught with difficulties. One response is to ignore the distinction, ignore the science and claim that all with Covid need a psychological therapist, but there is no scientific evidence for this – albeit that it suits the purposes of service providers to make such a claim. If you were not feeling ‘mildly anxious or depressed’ when you contract Covid that is probably very worrying!

An editorial in the British Medical Journal http://dx.doi.org/10.1136/bmj.m4425 bemoans the medico-political contexts that has hampered scientists expressing their concerns over the evidence base for handling Covid. But such a medico-political context has operated for years with regard to IAPT. There has been no independent evidence that IAPT’s work with sufferer’s from LTC’s has led to the resolution of accompanying psychological disorders. There has been no comparison with an active placebo or with the fate of LTC sufferers before the advent of IAPT.  The National Audit Office was allowed to suspend its’ investigation of IAPT in 2017, with no check on the appropriateness of having spent £4 billion of the public purse on the Service. Matters have been compounded by the BABCP’s (the lead organisation for cbt) unwavering support for IAPT and the British Psychological Society’s endorsement of IAPT training. Despite any evidence that the competence of therapists trained relates to client outcome Liness et al (2019) https://www.dropbox.com/s/e26n191ie09sngs/Competence%20and%20Outcome%20IAPT%20no%20relation%202019.pdf?dl=0.

2021 can only get better, one needs hope, I think that this is the message of Christmas.

Dr Mike Scott

IAPT’s Black Hole – Accountability

I recently asked the National Audit Office to restart it’s investigation into IAPT. I am expecting their reply in the next week or two. There has been no independent scrutiny of IAPT. They have been answerable only to Clinical Commissioning Groups, which have consisted largely of GPs and allowed IAPT to mark its’ own homework.

But the accountability gap also extends downwards, where is the evidence that front line staff or clients have been consulted or involved in decision making?  Most recently IAPT has offered webinars, for its staff on helping those with long term COVID.   There is a tacit assumption that this will be within the expertise of IAPT therapists just as helping those with long term physical conditions such as irritable bowel syndrome. But the IAPT staff working with LTCs were never consulted, before this new foray. Client’s with LTCs were never asked whether they were back to their old selves (or best functioning) before this proposed further extension of IAPT’s empire.  

In the forthcoming issue of the British Journal of Clinical Psychology I have challenged IAPT’s account of its ‘performance’ see ‘Ensuring IAPT Does What It Says On The Tin’ https://doi.org/10.1111/bjc.12264. There is a reply in rebuttal see ‘The costs and benefits of practice-based evidence: correcting some misunderstandings about the 10-year meta-analysis of IAPT studies’ https://doi.org/10.1111/bjc.12268 that reveals a breathtaking level of conflict of interests. IAPT and its’ fellow travellers should be held to account. But importantly they also need to account to their therapists and clients. [ The original IAPT paper is available at https://doi.org/10.1111/bjc.12259]

 

Dr Mike Scott

IAPT, No Better Than Placebo?

There is no compelling evidence that the Improving Access to Psychological Therapies (IAPT) service is any better than a placebo, yet its’ expansion continues to be funded, despite £4 billion having already having been spent on it. Barkham and Saxon (2018) https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-018-1899-0  in their study of IAPT, found a within subjects  overall effect size of 0.93, amongst clients attending a mean of 6-9 treatment sessions. [Effect size is calculated by subtracting the mean post-treatment score from the mean pre-treatment score and dividing by the pooled pretreatment standard deviation]. But Huneke et al (2020) https://doi.org/10.1017/ S0033291720003633 cite placebo effect sizes of between 0.65 to 1.29 in anxiety disorder outcome studies. This raises serious doubts on the added value of IAPT.  They further note that approximately 30% of patients in antidepressant and antipsychotic trials respond to placebo treatment. Whilst Barkham and Saxon indicate that 50% of IAPT clients make a reliable and clinically significant improvement, adjusting this figure for differences in the severity of mental illness, likely produces a response rate not obviously different to that in IAPT. 

However the above considerations are not definitive, IAPT’s performance has never been compared with an active control condition, leaving the jury out on its’ performance. Unfortunately this has left IAPT free to drain the public purse at will. The ultimate disgrace is that the Government/Public Health England have not subjected IAPT to independent scrutiny. Such a position would not be tolerated with regards to a vaccine, but it is apparently ok to look the other way on mental health.

Dr Mike Scott

A Psychological Wellbeing Practitioner’s Damning Indictment of Her Role

Last week a PWP (Psychological Wellbeing Practitioner) ALIEE November 25th 2020 put a post on this blog, calling for Panorama to take note of the desperate plight of PWPs – the main providers of services in the Improving Access to Psychological Therapies (IAPT) Service. Unfortunately the track record of the media in this regard is not good. It is a year since Radio 4 chose to broadcast predominantly the voices of  lead figures in IAPT and well known fellow travellers, rather than give expression to those at the coalface  and their clients.   One wonders what it takes for the media to wake up and ‘smell the coffee’ – £4billion has been spent on IAPT over the last decade all without any independent audit. Given the current, parlous state of Government finances this should at least come under independent critical review, perhaps by the Office for Budget Responsibility.

When a PWP candidly admits “I am trained to overlook the full picture”, it raises eyebrows. Then when ALIEE goes on to say that she operates purely with the ‘5 area model’,  this is jaw dropping.  This is not a model for any psychological disorder, by itself it is a heuristic for providing generic cbt, which has never been considered an evidence-supported treatment. Then this PWP states if clients still have high PHQ9 and GAD7 scores by the 4th session, it is the client who should be interrogated for their  competence in scoring, with the threat that if such scores persist there is the spectre of criticism from superiors. This is tantamount to fiddling results. It is atrocious that AIEE has been placed in this invidious position. I do not believe she is weak but rather like a prisoner at Auschwitz charged with the removal of dead bodies from a gas chamber.

The burden of proof is with IAPT to demonstrate that it has procedures in place to make it impossible for ALIEE to have been operating in this way. Protestations that ‘there a few bad apples’ in every workforce simply won’t wash.

Getting the media and politicians to listen is like getting the post war German Government to take action against war criminals. Action was only finally taken following many years of work by children of Holocaust victims. Unfortunately in the short term the implicit plea is that ‘we have enough to do with the Pandemic and Brexit, not to say Climate Change’ but the climate of the upcoming generation is affected by the mental health of today’s adults. 

Dr Mike Scott

IAPT’s Hall of Mirrors Feedback

negates improved practice. The Organisation’s usage of the Patient Experience Questionnaire (PEQ) violates all the key requirements for eliciting feedback, which has to involve:

a) a response to questions that have an unambiguous real world meaning e.g ‘are you back to your old self  since treatment? i.e questions have to have validity

b) drawing upon a consecutive series of clients

c) completion anonymously and not in the presence of the therapist

d) a representative sample.

IAPT makes a token gesture of soliciting feedback using the Patients Experience questionnaire,  but its’ modus operandi is such that it cannot furnish a body of evidence that would demonstrate that it is not a ‘world beater’. In effect it has operated with a confirmatory bias only seeking information that would confirm its’ prior belief.

In 2016-2017, of 219 Clinical Commissioning Groups in England, 55 (25%) produced no PEQ data at all, i.e that a quarter of CCGs were funding a service in the absence of any evidence that the IAPT Service was eliciting feedback. In 2017-2018 of the 554,709 clients who completed a course of treatment  only 22% Moller et al (2019) https://doi.org/10.1186/s12888-019-2235-z completed the treatment questions on the PEQ.

There is no evidence that IAPT took active steps to ensure completion by consecutive cases or that therapists were blind to the results of the PEQ. The questions on the PEQ are themselves of doubtful validity e.g ‘how satisfied are you with your assessment’, this  question presupposes that the client has the knowledge base as to what constitutes a good assessment, imagine  if asked this question as a possible COVID patient most of us would believe ‘it is outside my expertise to judge the matter’. The question on the PEQ ‘on reflection, did you get the help that mattered to you’ is ambiguous, is it asking about the emotional significance of the encounter with the therapist, for example did they really listen/seem to care or about whether as a result of treatment you had returned to normal functioning.

Government and Clinical Commissioning Groups have turned a blind eye to IAPT’s failure to systematically elicit feedback from clients. At a cost of £4billion over the last decade and an incalcu cost to mental health. sufferers.

Dr Mike Scott

 

 

‘CBT Is Not A Treatment Or Cure for ME/CFS’

announced NICE in its’ draft guidance, https://t.co/OWJjzbQGqK?amp=1 on November 10th 2020. This is likely to come as a shock to Improving Access to Psychological Therapies (IAPT) Service clinicians charged with delivering treatment to patients with Medically Unexplained symptoms, a term which embraces chronic fatigue syndrome (CFS) sufferers, those with musculo- skeletal pain and those with irritable bowel syndrome.  Will the IAPT clinicians explain to CFS sufferers that they are not providing treatment, just helping them ‘manage their symptoms’ as NICE now recommends?.

Will they tell their client that they don’t know what the odds are that the programme will make them ‘manage their symptoms’ better?  

It will no longer be credible for IAPT workers to present the CBT model of MUS which posits that the latter is a product of an interaction of personality factors like perfectionism, illness beliefs (attributions), cognitions (catastrophising), and behaviours such as symptom focusing (somatising) and avoiding activity (due to fear-avoidance or anxiety), (albeit that biological factors are acknowledged but given no explanatory powers). If indeed this CBT model is at the core of the pathology underpinning CFS, then CBT treatments should have resolved the disorder and not simply have helped sufferers ‘manage their symptoms’.  

IAPT assesses the competence of its CFS clinicians, in part, by whether they explain the CBT model of MUS. They need an urgent rethink.  How many of its’ therapists have they stressed out by asking them to promulgate a model that doesn’t deserve the term. It is not surprising that when Keith Geraghty and I (2020) reviewed IAPT data doi: 10.1186/s40359-020-0380-2 we found that only 4.6% of the MUS patients IAPT taken into treatment, complete intensive CBT.

NICE have taken seriously the views of sufferers and the experiences of clinicians and have been unimpressed by the quality of studies on the effectiveness of CBT for CFS. Unfortunately consumer and clinicians views on CBT meted out in routine IAPT practice,  for supposedly depression and the anxiety disorders, have yet to be elicited and what we have been offered is research evidence that is far from compelling,  Scott (2020) https://doi.org/10.1111/bjc.12264. 

Professor Jonathan Edwards submission to the NICE guideline Committee are a must read he highlights the importance of support over treatment:

much more emphasis is needed on ongoing support, rather than the use of short treatment courses. Perhaps the greatest missed opportunity of trials focussing on stereotyped treatment modalities is a failure to recognise the value of support from experienced carers that simply aims to make life easier to cope with, rather than address a theoretical model’

His is a clarion call  for basic humanity, being with people rather than believing that everything is fixable, walking the road with them. This should not be put under a CBT umbrella, to do so is a gross imperialism. Professor Edwards strictures  on the research are exemplary:

 ‘all the studies that claim to show benefit from therapist-delivered treatments in ME/CFS are unblinded trials that make use of subjective outcome measures… ….unblinded trials with subjective outcomes are specifically considered unreliable’ 

He goes on to  detail why such methodological rigour is required such as finding that repeating an experiment with unblinded assessors has discredited the initial positive findings and the problems of not taking seriously allegiance bias and none declaration of conflicts of interest. professor Edwards addresses the issue of honesty thus on p10 of his submission:

Patients are entitled to be fully informed, based on reliable evidence. As I understand it, patients receiving CBT are not told that the explanation given for the illness is speculative, that there is no reliable evidence for the efficacy of the treatment or that objective measurements and long-term follow-up suggests there is none of consequence. Convincing the patient that the explanation of the illness is correct, and that the treatment is effective, appear to be inherent to the way CBT is supposed to work. It would therefore appear to be unethical to continue development and use of CBT based on the current approach of altering beliefs about e.g. disease causation or effects of exercise’.

But exactly the same critique can be applied to IAPT’s low intensity CBT interventions.

 

 

Dr Mike Scott