‘What Is Going On, When The Dose of Psychological Therapy Is Less Than Half That Recommended By The National Institute for Health and Care Excellence (NICE)?’

 

a recent study by Saunders et al (2021) Journal of Affective Disorders 294 (2021) 85-93 found that the average client in the Improving Access to Psychological Therapies  (IAPT) low intensity therapy has 3 sessions ( a mean of 2.85 sd 2.81) whilst the average client in high intensity therapy has 5 sessions ( a  mean 4.79 sd 5.51). But the IAPT Manual (2021) p51 states ‘should be offered up to the NICE-recommended number of sessions for the relevant clinical condition. For high-intensity work this would generally be in the range of 12 to 20 sessions’, Further the low intensity intervention such as the Stress Control Programme typically involve 6 sessions. Clearly IAPT clients are receiving a sub-therapeutic dose of treatment. Yet astonishingly IAPT claims that it is NICE compliant!

But IAPT uses a language that is reminiscent of Alice In Wonderland, treatment is defined as attending at least two treatment sessions. This means that those who miss their first treatment appoint [40% according to Davis, A., Smith, T., Talbot, J., Eldridge, C., & Betts, D. (2020). Predicting patient engagement in IAPT services: a statistical analysis of electronic health records. Evidence-based mental health, 23(1), 8–14. https://doi.org/10.1136/ebmental-2019-300133] or attend only one session [42% according to Davis, A., Smith, T., Talbot, J., Eldridge, C., & Betts, D. (2020). Predicting patient engagement in IAPT services: a statistical analysis of electronic health records. Evidence-based mental health, 23(1), 8–14. https://doi.org/10.1136/ebmental-2019-300133] are not counted as part of those treated, but they in total constitute 64% of those passing through the IAPT starting gate. Thus approximately two thirds of the would be beneficiaries of IAPT’s ministrations refuse to take their medicine! Add this into the equation and the services performance looks woeful.

 

IAPT uses a sleight of hand to claim NICE compliance (a sine qua non of funding by Clinical Commissioning Groups CCGs). It asks its’ therapists to use ‘problem descriptors’ to select an ICD code (the World health Organisations coding system for diagnosed disorders). But an ICD code is only as reliable as the diagnosis and IAPT therapists do not make diagnoses, how then can they provide treatment ‘for the relevant clinical condition’ p51 IAPT Manual (2021)?  GPs clearly make diagnoses and their records often mention problems associated with the diagnosis, but they do not make the diagnosis on the basis of those problems, they are qualitatively different types of information. An IAPT therapist like a social worker may note psychosocial stressors but any mention of disorder would not be taken as evidence of disorder in a Court of law.  Where IAPT therapists to claim they made a diagnosis that would be subject to legal challenge and the Organisation steers its employees away from this.

Many IAPT therapists are delighted with this as they see ‘diagnosis’ as akin to blasphemy. NHS England and CCG’s, refuse to acknowledge the elephant in the room, they have chosen to totally avert their gaze from this problem, preferring to sup with the IAPT hierarchy.

 

Dr Mike Scott

 

Group Interventions A Manager’s Dream But A Clients….?

As the pandemic recedes and concerns about scarcity of individual therapy continues, there are likely to be increased calls for group interventions, whether psychoeducational or psychotherapeutic.  But the vexed question has to be asked, does the particular group intervention envisaged make a real world difference to client’s life? Is the group intervention more to do with appearing to have done something? 

There are protocols for depression and the anxiety disorders described in my book Simply Effective Group CBT (2011) London: Routledge.

The content for the group sessions I detailed in the book can be downloaded by clicking the link below:

https://www.dropbox.com/s/ys0ogfo3k93qmwb/Ptsd%20Group%20treatments%202018.pdf?dl=0

But I have a number of concerns about the utilisation of group interventions in the IAPT-ification of psychological therapy services. There is a danger of spin with regards to group CBT. This can happen easily by taking the abstracts of studies at face value, when many of the authors have developed the protocols that they are evaluating – allegiance bias. I doubt whether, despite the best efforts of any training institution, there will be a monitoring of fidelity to evidence-based protocols and a meaningful assessment of outcome. In practice clients may be short-changed by Group CBT and may then be put off further therapy. Whilst the group interventions may be intended as part of a stepped care package, clients are least likely to attend the appointment that marks the start of the new dawn [ Davis et al (2020)https://doi.org/10.1136/ebmental-2019-300133].  The following critique of group studies may be useful:

  1. Group psychoeducation interventions have an appeal that belies evidence of their effectiveness. I can find no study in which there has been independent assessment of effectiveness using a standardised diagnostic interview. Thus it is not known what proportion of sufferers with a particular disorder would lose their diagnostic status as a result of treatment, much less how enduring recovery would be. ‘No longer suffering from a disorder’ is a metric that a member of the public can readily understand, but to be told that you no longer require treatment because you are now below ‘caseness’ on a psychometric test is likely to produce a puzzlement, that the client is too polite or disadvantaged to challenge.
  2. It may be to the advantage of Managers  and Academic institutions to promote psychoeducational groups but to the pay-off for the client is what? The experience of group involvement may not be adverse, they may have even enjoyed the sense of belonging that has come from group attendance, but if at the end of the day it has not made a real world difference to the client’s life, was it worthwhile? The issue of group psychoeducation has to be approached from a bottom-up perspective not top-down.  Ost (2008) Outcome studies Quality Ost 2008  has published a 22 item measure of the reliability of psychotherapy outcome studies, each item is rated 0-2, so that a score of 44 is possible. Applying this measure to the most popularly delivered psychoeducation group Stress Control, I found yielded a score of 9, but the mean score in CBT outcome studies was 28 and Ost suggested that studies with scores of 19 or below could not be considered empirically supported treatments. Failings of the recent SC studies (the original White et al study fared slightly better because it specified a particular diagnosis, GAD) included amongst others the following domains: reliability of the diagnosis, specificity of outcome measure, blind evaluation, assessor training, design, assessment points, controlling for concomitant treatment, and assessment of clinical significance.

3. In a paper titled “Are individual and group treatments equally effective in the treatment of depression in adults? Cuijpers et al answered with a cautious ‘yes’. They drew upon my own study [ Scott and Stradling (1990)https://doi.org/10.1017/S014134730001795X ] comparing individual and group CBT with a waiting list, but did not mention that in order to get the group CBT to be a viable entity, we had to offer up to 3 individual sessions concurrently, though interestingly few took up all three.  Selling the group CBT was a challenge, however both modalities were equally effective and I think Cuijpers et al’s conclusion is appropriate. 

4. In 2018 carpenter et al published https://doi.org/10.1002/da.22728 a study of the efficacy of CBT for anxiety disorders. They considered only studies in which the comparison condition was a psychological placebo e.g supportive counselling i.e one in which there is a credible rationale, this controls for common factors such as the therapeutic alliance. Carpenter et al found only 7 studies comparing individual and group CBT with these provisos, and for only 2 disorders social anxiety disorder and PTSD was their sufficient data to reach conclusions and in both instances individual CBT was superior to group CBT.

But in 2020 Barkowski et al Group CBT for anxety dsorders 2020 published a meta analyses of group psychotherapy and claimed that group psychotherapy  for anxiety disorders  is more effective than active treatment controls.  They cite a Hedges g effect size of 0.29. But these authors fail to point that this effect size is small. A Hedges g of 0.2 would mean that the average person in the largely CBT groups would have done better than 58% of those in the control condition. Whether these differences are clinically significant is a matter of debate. Further only 3 anxiety disorders were considered GAD, panic disorder and social anxiety disorder, the results do not apply to OCD or PTSD (which historically was placed in the anxiety disorders but now no longer is). The authors proclaim that mixed-diagnoses groups are equally effective as diagnostic specific groups. But this is misleading, the most recently published group trans diagnostic study by Roberge et al (2020) Group transdiagnostic cognitive-behavior therapy for anxiety disorders: a pragmatic randomized clini had approx half of clients (52.8%) suffering from generalised anxiety disorder and approx a third (29.4%) suffering from social anxiety disorder, thus over 80% of the clients are suffering primarily from either one or the other of just 2 disorders, more accurately it should be termed limited transdiagnostic therapy.  Further clients were recruited via newspaper advertisements, 86% of the clients were women and 42% had a University Diploma, only half of clients were completers i.e attended 8 or more of the treatment sessions, and only half lost their principal diagnosis.  Making generalising from these studies problematic.

The danger is that group devotees look simply at the abstracts of the group studies, without realising that the authors were the developers of the protocols and their findings need taking with a great deal of caution. My worry is that IAPT in particular will seize on groups as a way forward in a numbers game and clients will be short changed.

Dr Mike Scott

Stopped Care Replaces Stepped Care in IAPT

over 70% (73.3%) of the Improving Access to Psychological Therapies (IAPT) clients are offered low intensity treatment (such as computer assisted CBT, group psychoeducation or guided self-help) first, and only 4% (4.1%) are then stepped up to high intensity treatment. The first transition appointment is the least well attended [ Davis et al (2020) https://doi.org/10.1136/ebmental-2019-300133]. 

IAPT clients haemorrhage from the system at the outset, 40% of first appointments are missed and 42% of clients attend only one treatment session. But IAPT’s claimed recovery rate of 50% applies only to those who complete two or more treatment sessions. The suspicion is that real world recovery rate is much less. Examination of the trajectory of 90 IAPT  clients using a gold standard diagnostic interview [ Scott (2018) IAPT The Need for Radical Reform, Journal of Health Psychology https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0.] suggests only the tip of the iceberg recover.

A small proportion of IAPT clients (16.4%) are offered high intensity first. The IAPT Manual recommends that this should occur for clients suffering from PTSD, social anxiety disorder or severe depression.  But offers no reliable methodology for deciding who is in what category. The agency claims it does not do ‘formal diagnosis’. 

 

How are clients to be directed to appropriate care?

 

Dr Mike Scott

Constant Breaches of Conflict of Interest By IAPT and NHS England

the latest example comes from Saunders et al  (2021) in the Journal of Affective Disorders 294 (2021) 85-93 https://doi.org/10.1016/j.jad.2021.06.084. None of the 9 cited authors acknowledge any conflict of interest. But the database they draw upon is from the Improving Access to Psychological Therapies (IAPT) treatment programme, 2 of the 9 work for iCope an IAPT service, as well as being part of a research network of IAPT and academics, 4 others are also part of the IAPT Service Improvement and Research Network (SIRN). Their paper is titled ‘Older adults respond better to psychological therapy than working age adults: evidence from a large sample of mental health service attendees’.  The authors note that their finding runs counter to other studies that have suggested interventions for depression are equally effective when comparing older to working age adults and even that older adults suffering from anxiety disorders have worse outcomes than working-age patients. They are curiously blind to the possibility that the IAPT database is suspect, that it does not measure what it purports to  do so. There is a clear operation of allegiance bias. Readers and Journal editors have a right to be alerted to the possibility of allegiance bias by a transparent declaration of conflicts of interest. I wrote to the Journal Editor about this but he declined to publish my letter.

 

  1. Earlier this year I wrote a blog on  a study by Barkham et al (2021) https://doi.org/10.1186/s12888-018-1899-0 which involved comparison of person-centred counselling and cognitive behaviour therapy (cbt) in a high intensity therapy service delivered by IAPT. Curiously patients were screened for the study using the Clinician Interview Schedule Revised but neither this nor any standardised diagnostic interview was used as an outcome measure. Further Barkham et al (2021) chose to adopt the Improving Access to Psychological Therapies (IAPT) primary outcome measures the PHQ-9 [Kroenke et al (2001)] and GAD-7 [Spitzer et al (2006)], without any discussion. There is no comment that these are self-report measures, subject to demand characteristics and that changes are impossible to interpret without comparison to an active placebo treatment. Why such apparent blindness? The answer is apparent reading the declaration of conflicts of interest, the authors are either devotees of person-centred counselling or have links with IAPT. Their take home message is that person centred counselling might be better than CBT for depressed patients. But there is no attempt to address the question of what proportion of patients lost their diagnosis status and for how long, as determined by an independent blind clinical assessment using a standardised interview. Service-users interests are ill-served by this type of study which additionally ignored data that suggest the recovery rate in IAPT is just 10% [Scott (2018)]https://doi.org/10.1177/1359105318755264 .
  2. IAPT is the biggest provider of group psychoeducation and it was given a boost by a Dolan et al (2021) study all authors declared no conflict of interest. But the corresponding author for the Dolan et al (2021) study is a programme director of IAPT and another of the authors has IAPT involvement.Dolan, N., Simmonds-Buckley, M., Kellett, S., Siddell, E., & Delgadillo, J. (2021). Effectiveness of stress control large group psychoeducation for anxiety and depression: Systematic review and meta-analysis. The British journal of clinical psychology60(3), 375–399. https://doi.org/10.1111/bjc.12288

 

3. In March 2021 the British Journal of Clinical Psychology published my Commentary ‘Ensuring IAPT Does What It Says On The Tin’ I wrote ‘In the Wakefield et al. (2020) paper all the authors declare ‘no conflict of interest’. But the corresponding author of the study, Stephen Kellett, is an IAPT Programme Director. The study is therefore open to a charge of allegiance bias. It is therefore not surprising that Wakefield et al. (2020) fail to make the distinction between IAPT’s studies and IAPT studies. By definition, the former have a vested interest, akin to drug manufacturer espousing the virtues of its psychotropic drug. Whilst an IAPT study is conducted by a body or individual without a vested interest, in this connection Wakefield et al. (2020) have implicitly misclassified this author’s IAPT study, Scott (2018). In their study, Wakefield et al. (2020) make reference to the Scott (2018) study with a focus on a subsample of 29 clients (from the 90 IAPT clients) for whom psychometric test results were available in the GP records. But in Scott (2018) it was made clear that concluding anything from such a subsample was extremely hazardous. The bigger picture was that 90 IAPT clients were independently assessed using a ‘gold standard’ diagnostic interview, either before or after their personal injury (PI) claim. Independent of their PI status, it was found that only the tip of the iceberg lost their diagnostic status as a result of IAPT treatment. Wakefield et al. (2020) were strangely mute on this point. They similarly failed to acknowledge that the ‘IAPT’s studies’ involved no independent assessment of IAPT client’s functioning and there was no use of a ‘gold standard’ diagnostic interview.’

 

Failure to declare conflicts of interest is not confined to Journals but also operates in NHS England who direct Clinical Commissioning Groups. IAPT staff are employed by NHS England, the latter has no independent body overseeing IAPT and it is therefore unsurprising  that the expansion of the service is given wholesale backing.

Current NHS England team

Sarah Holloway, Head of Mental Health, NHS England
Xanthe Townend, Programme Lead – IAPT & Dementia, NHS England

David M. Clark, Professor and Chair of Experimental Psychology, University of Oxford; National Clinical and Informatics Adviser for IAPT

Adrian Whittington, National Lead for Psychological Professions, NHSE/I and HEE; IAPT National Clinical Advisor: Education

Jullie Tran Graham, Senior IAPT Programme Manager

Hayley Matthews, IAPT Programme Manager, NHS England

Andrew Armitage, IAPT Senior Project Manager, NHS England

Sarah Wood, IAPT Project Manager, NHS England

 

Dr  Mike Scott

References

Barkham, M., Saxon, D., Hardy, G. E., Bradburn, M., Galloway, D., Wickramasekera, N., Keetharuth, A. D., Bower, P., King, M., Elliott, R., Gabriel, L., Kellett, S., Shaw, S., Wilkinson, T., Connell, J., Harrison, P., Ardern, K., Bishop-Edwards, L., Ashley, K., Ohlsen, S., … Brazier, J. E. (2021). Person-centred experiential therapy versus cognitive behavioural therapy delivered in the English Improving Access to Psychological Therapies service for the treatment of moderate or severe depression (PRaCTICED): a pragmatic, randomised, non-inferiority trial. The lancet. Psychiatry, 8(6), 487–499. https://doi.org/10.1016/S2215-0366(21)00083-3

Scott M. J. (2018). Improving Access to Psychological Therapies (IAPT) – The Need for Radical Reform. Journal of health psychology23(9), 1136–1147. https://doi.org/10.1177/1359105318755264

 

Scott M. J. (2021). Ensuring that the Improving Access to Psychological Therapies (IAPT) programme does what it says on the tin. The British journal of clinical psychology60(1), 38–41. https://doi.org/10.1111/bjc.12264

 

 

 

IAPT – Many Visitors But Few Customers

 

If you are a visitor to the Improving Access to Psychological Therapies (IAPT) service there is a 1 in 4 (27%) chance of recovery [Walker, C., Speed, E. & Taggart, D. Turning psychology into policy: a case of square pegs and round holes?. Palgrave Commun 4, 108 (2018). https://doi.org/10.1057/s41599-018-0159-8] using the services’ own metric. But IAPT claims a 50% recovery rate. However if you read the fine print, this claim actually relates to those clients who complete two or more treatment sessions – a completer rather than intention to treat analysis.

 

According to the UK Governments Improving Access to Psychological Therapies (IAPT) annual report for 2019-2020 – 489,547 people curtailed involvement after having one treatment appointment, whilst 606,192 had two or more treatment sessions. Thus almost as many people have just one treatment session as two or more. Of 1.69 million referrals to IAPT in 2019-2020, 1.17 million left the starting gate, 30.77% (almost 1 in 3) were non-starters. IAPT’s compiler analysis is misleading.

But applying the metric of the proportion of clients who lose their diagnostic status, only the tip of the iceberg recover, Scott (2018) IAPT The Need for Radical Reform, Journal of Health Psychology https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0. If the consumers of services ruled, the Improving Access to Psychological Therapies (IAPT) service would go out of business.

But IAPT is answerable to no one. NHS England monitors the quality of inpatient mental health services  via the Care Quality Commission (CQC). For example CQC feedback persuaded NHS England to challenge the quality of Child and Adolescent Mental Health Services run by Cygnet. But the CQC has no such remit over IAPT. 

 
Turning psychology into policy: a case of square pegs and round holes?
Carl Walker1, Ewen Speed2 & Danny Taggart2

ABSTRACT

This paper problematizes the ways in which the policy process is conceived in published psychological research. It argues that these conceptions of the policy process fail to ade- quately reflect the real-world dynamism and complexity of the processes and practices of social policy-making and implementation. In this context, psychological evidence needs to be seen as one type of evidence (amongst many others). In turn this requires researchers to take account of broader political processes that favour certain types of knowledge and disparage others. Rather than be regarded as objective and scientific, policy in this characterisation is regarded as a motivated form of politics. This multi-layered, multi-level hybrid structure is not immediately amenable to the well-intentioned interventions of psychologists. While the tendency of many psychologists is to overestimate the impact that we can have upon policy formation and implementation, there are examples where psychological theory and research has fed directly into UK policy developments in recent years. This paper draws on the recent Improving Access to Psychological Therapies (IAPT) initiative and the work of personality researcher Adam Perkins on the UK’s social security system to ask whether psychology has a sufficiently elaborated sense of its own evidence base to legitimately seek to influence key national areas of public policy. The article cautions against dramatic changes to policy pre- dicated upon any one reading of the variegated and, at times, contradictory psychological evidence base. It concludes that, in order to meaningfully contribute to the policy develop- ment process in a way which increases equality and social justice, psychologists need to be more strategic in thinking about how their research is likely to be represented and mis- represented in any particular context. Finally some possible directions for psychologists to take for a more meaningful relationship with policy are suggested.
1 Applied Social Science, University of Brighton, Brighton, UK. 2 School of Health and Social Care, University of Essex, Essex, UK. Correspondence and requests for materials should be addressed to C.W. (email: C.J.Walker@brighton.ac.uk)
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PALGRAVE COMMUNICATIONS | DOI: 10.1057/s41599-018-0159-8
RTepresentations of policy in psychological research
he original ‘scientist of happiness’ Jeremy Bentham is commonly regarded as the individual who, more than any other, brought the phenomenon of ‘evidence based policy making’ into being. The sociologist Will Davies states that, “Whenever a policy is evaluated for its measurable outcomes, or assessed for its efficiency using cost benefit analysis, Bentham’s influence is present.” (2015). It is important to bear this influence in mind therefore, when almost 250 years later, the discipline of psychology (via the ‘measurement’ of human experience), is aiming to stake a claim for a central role at the heart of the UK policy agenda.

At issue here is the way in which much academic research, and psychological research in particular, conceives of, and engages with, policy processes. Typically, this involves a naïve reading of policy context (which happens somewhere else, away from the disciplinary context of the research) which is painted as uni- dimensional and something that can be relatively easily influ- enced, with no need to address questions of complexity, or other disciplinary and professional boundaries. The assumption tends to be that policy should come to their research, rather than thinking (concretely) about how they, themselves, not some ghostly, ill-defined (and supplicant) policy actor, might make their research policy relevant for them. This fundamental lack of connection with existing policy processes, demonstrates as Cair- ney (2016) has argued, that researchers are engaging with the policy process that they wish existed rather than the processes which actually exists. The policy processes which do exist are predicated upon internal and external hierarchies of evidence, and processes and practices of influence, patronage and lobbying which are far removed from two throw away lines in the con- clusion of an academic paper stating that the preceding research has policy relevance and impelling policy makers to sit up and take notice (whomsoever those policymakers might be-they are seldom if ever identified). This is to say nothing of the wider ideologically framed political and discursive formations that influence what it is possible to imagine in a policy arena at any one place or time.

To illustrate this complexity, and the attendant constraints upon psychological research impacting upon the policy process, we take an example where psychological research has been adopted in a highly selective way; the development of psycholo- gical treatments for common mental health issues. Our argument is that, in order to meaningfully contribute to the policy devel- opment process in a way which increases equality and social justice, psychologists need to be more strategic in thinking about how their research is likely to be represented and misrepresented in any particular context. This requires a political awareness and engagement that historically psychologists, in the interests of scientific distance, have been wary of.

In terms of the political context, the ghost of utilitarianism looms large. A rigid hierarchy of evidence, primarily predicated upon questions of economic value (broadly construed), dom- inates the field (Cairney, 2016). Even then, even if the paper has the highest standard of evidence, this does not necessarily guar- antee that this evidence will be picked up by policy makers or politicians. If there is no political case for the policy, there will be little chance of the evidence being implemented in a policy context. The point is that demonstrating economic value is not enough, there is also a clear and present need to demonstrate the political expediency of any proposed policy, (regardless of the evidence). It is in this context that we see policy-based evidence, rather than evidence based policy (see Cairney, 2018), where policymakers may make very selective use of the evidence in a
way that supports their view and denigrates another view. Con- sider the implications of this dynamic process for an academic paper which claims policy relevance, but does not direct this to a when or a where. In this context the academic research could, it is argued, be up for grabs, ready and able to deployed in any number of ways, that may, or may not contradict the intention of the original research.

Earlier we argued that this insistence, on the part of psychol- ogists, reflects a naïve reading of the policy context. Furthermore, this failure to engage with the dynamic complexity of policy practices and processes runs the risk of reifying this mis- characterisation. Such is the vagaries and iniquities of the policy process that there is a need to acknowledge and address these vagaries if research is to have a meaningful and significant impact. There is a compelling evidence that outlines the way that policies are often driven by ideology and biases rather than evidence (Fishbeyn, 2015, Prinja, 2010). Cleary then, there is a danger that psychological research, which argued position X, can and will be taken up by politicians or policy makers and deployed in a way which argues position Y. And, if the characterisation of the policy process envisaged by researchers is the reified mischaracterisation we outline above, the danger of this misrepresentation of the tone and tenor of academic research becomes far more likely to occur, as policy makers and politicians assert their dominance (over the evidence makers, i.e., academic researchers) in the policy arena.

All of this talk relates to issues in and around the policy pro- cess, that is to say, the practice of social policy, how it works. But there is also a need to address issues of context, those social, political, economic and cultural spheres where the practice of social policy is enacted. There is a clear need to conceive of the relation between these different spheres in terms of the influence and impact that psychology might have on policy process and practice, but also, in terms of the influence and impact that policy might have on psychology. Failure to consider this ‘to-and fro’, or ‘ebb and flow’ would run as much of a risk of policymakers reifying psychological research as the obverse process we set out here.

This requires psychologists, as a professional group, to give serious discussion and debate to what they are doing in a broader social, political economic and cultural context. It requires psy- chologists to raise questions about how they should (or should not) contribute to policy. Moreover, questions about the relia- bility of the psychological evidence base, as well as a tendency to celebrate the statistical flukes left standing after researchers have cast around to find publishable positive results (Rhodes, 2015) has left psychologists Farsides and Sparks (2015) to suggest that ‘psychology is liberally sprayed with bullshit’ (p368).

IAPT, the welfare trait and ‘policy-ready’ psychology
While the tendency of many psychologists is to overestimate the impact that we can have upon policy formation and imple- mentation, there are examples where psychological theory and research has fed directly into UK policy developments in recent years, with some influence. By focusing on a high profile example we can then examine not only if psychology has an impact but more importantly what that impact has been.

The Improving Access to Psychological Therapies (IAPT) initiative is arguably the jewel in the crown of applied psychol- ogy’s influence on UK mental health policy, with the rest of the world taking note (NYT, 2017). Based on an elegant economic cost-saving calculation (the ghost of Bentham again), by the UKs‘Happiness Tsar’ and economist Richard Layard, combined with evidence-based psychological therapies (primarily CBT), one could reasonably ask what’s not to like? While we of course can see the value in the opportunity for many thousands of people to
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undertake a course of psychological therapy to alleviate their mental health issues and to bring an important psychosocial dimension into mainstream mental health care, there are unin- tended and unhelpful consequences of the IAPT agenda that need to be considered.

Firstly, as with many policy initiatives, there is the gap between the political rhetoric and the clinical reality. IAPT has, from the beginning, made ambitious claims about its effectiveness, offering treatment to 900,000 patients annually and achieving a 50% recovery rate for depression, anxiety and related ‘common mental health problems.’ (Clark, 2011). It should be borne in mind that this level of treatment was necessitated in order to produce the ‘zero net cost’ of IAPT at the policy development stage through promising savings in physical health care, numbers of welfare claimants and a reduction in mental health related sick days (Clark, 2011).

Whilst IAPT has lived up to some of these promises, with undoubted successes in treatment effectiveness (recovery figures approaching 50% for those who complete treatment, NHS Digital, 2017), there is some cause for concern around evidence that the ‘IAPT effect’ has not been entirely benign. For example, in IAPT monthly data summary for December 2017 NHS data (NHS Digital, 2017), 89,485 new referrals were received with 68,205 referrals entering treatment. Of this number 39,834 completed a course of treatment with 37,238 starting treatment with ‘caseness’ (the referral has enough symptoms to be regarded as clinical) and 49.9% of those approaching recovery by the end of treatment. This data means that only 22.25% of the total referrals were considered to be getting better. That means that in this month over 72% of referrals coming for help either did not receive any treatment at all, did not receive a full course of treatment or did not get better by IAPT’s own metrics.

If we are more conservative and remove those who did not start treatment from our calculation, the situation improves slightly to 27% of referrals achieving recovery and even if we assume that one referral does not equate to one person, that is still a lot of disappointed, disillusioned and worried people. Given that these dropout figures are roughly comparable with other time points in IAPT’s history (McInnes, 2014) this is cause for con- cern. Add to this the study which found that, for a sample who did achieve recovery using low intensity forms of IAPT, 53% relapsed within one year (Ali et al., 2017) and we can see that the more carefully we look at the psychological evidence base for IAPT policy the more questions arise.

Given widespread reductions to specialist mental health ser- vices, it seems likely that IAPT, a brief, often self-directed form of psychological treatment for mild to moderate mental health issues is being expected to plug the gap left by the reduction in longer term community services. As Watts (2016) points out, in IAPT’s own analysis dropout figures are not seen as a criticism of the initiative itself as they are not counted in recovery figures. Fur- thermore, in trying to bring people into services in order to meet policy-based treatment targets we may inadvertently be creating need in people and then not meeting it, a particularly ‘perverse form of care’ likely to have a detrimental impact on the mental health of many left behind by the IAPT revolution.

Additional evidence demonstrates that the number of people not recovering through IAPT approved CBT are dis- proportionately from poorer communities (Delgadillo et al., 2015). In the 2015–2016 IAPT annual report (NHS Digital, 2016), 55% of referrals in the least deprived 10% of areas achieved recovery, while in the most deprived 10% of areas only 35% achieved recovery. This can be likened to an extension of the ‘inverse care law’ whereby not only do people in more disadvantaged com- munities struggle more to get access to healthcare, when they do it is less effective in helping their mental health. To what extent this is a failing of IAPT per se and how much it reflects the causes of
common mental health issues in disadvantaged communities being less psychological and more social (Speed and Taggart, 2012) is beyond the scope of this paper but is also worth con- sidering when assessing psychology’s readiness to take an intrapsychic perspective to the exclusion of other models.

From this we can begin to see that laudable claims of treating common mental health issues for hundreds of thousands of people annually involves unintended consequences of alienating many from trusting services and repeating the pattern of further mar- ginalising those already structurally disadvantaged. Indeed, it is our argument that it is the very ‘policy ready’ nature of IAPT that has precipitated many of these unintended consequences. Its grand, possibly hubristic vision of ‘curing’ common mental health issues and reducing the economic burden of the ‘mentally ill’ undoubtedly plays well in a political era that privileges an instrumentalist, Fordist and market-oriented approach to public services, but the scale of the claims needed to provide a ‘bottom line’ appeal was always likely to demand much and leave many staff and patients behind. This is largely because Benthamite cost-benefit analyses are not a sufficient basis upon which to predicate the policy and practice of mental health care because they ignore the processes and contexts of mental health, out there, in the world.

Another source of ‘policy-ready’ psychological research comes from the personality researcher Adam Perkins in his work ‘The Welfare Trait’ (2015). Perkins makes a case for a fundamental restructuring of the UK’s social security system based on an assertion that overly generous welfare provision for out-of-work parents results in the proliferation of what he describes as an ‘Employment Resistant Personality’ profile that leads to welfare claimants having more children and negatively impacting national productivity. Whilst questions have been raised about whether this work is of merit as psychological science, the issue we want to address here is whether psychology has a sufficiently elaborated sense of its own evidence base to seek to influence a key national area of public policy as social security?

To take the Welfare Trait example, even Perkins notes the perverse logic in cutting welfare payments for families with multiple children, thereby depriving already disadvantaged chil- dren of resources. On this point there is a consensus of agree- ment. However, Perkins draws from a 1975 study (Tonge et al. 1975) of 33 Sheffield families to suggest that this perverse logic can be ignored as welfare claimants all “spend their welfare benefits on unnecessary purchases such as electronic gadgets and luxury chocolates, instead of using the money to improve the lives of their children.” (Perkins, 2015 p.177). This conclusion seems emotive and polemical rather than being based on any robust evidence. This conclusion on the part of Perkins is clearly not the type of psychological evidence that we want to use to determine the life chances of millions of children.

When we add a competing example of psychological evidence, an analysis which found that levels of referral for maltreatment were causally related to the income variation in low income families in the US (Cancian et al. 2010) with reductions in income leading to an increases in maltreatment cases, we can see that dramatic changes to welfare policy predicated upon any one reading of the variegated and at times contradictory psychological evidence base can be downright dangerous.

Concluding thoughts

We would like to end by urging caution on psychologists who aim to have a ‘policy impact’. Instead, we suggest a level of professional engagement in policy processes, whereby psychological evidence is used to forge alliances with common interest groups, for example, to lobby ministers for particular reforms or new initiatives. So rather than merely referencing policy implications in research
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papers, there is a wider social undertaking to make research evi- dence available to communities impacted by the social problems under investigation in order to enable them to petition for change.

In some mental health research contexts this is already hap- pening, where alliances have been formed between psychological researchers and mental health service user groups. In the Understanding Psychosis (2014) project there is a clear move towards the dissemination of research findings regarding aetiol- ogy, symptomatology and treatment for psychoses and associated mental health issues that largely draws upon preexisting psy- chological research alongside first person testimonies and acti- vism from people with that diagnosis. Therefore, in this case the research acts as a form of social activism in which evidence is used explicitly in the interests of those it purports to be about, allowing them a very real, present and active voice in talk about their mental health. However, there is a bind that comes with this ‘bottom up’ approach to influence, and it is one that resonates with the naivety (even futility) of claims regarding the policy relevance of psychological research that we critiqued in this paper. Unless there is a vested interest policy actor working with the psychological researchers, the chance of any research gaining any degree of purchase in the field is at best limited.

The great achievement of the IAPT agenda was the alignment of psychological evidence, the vested interests of the profession of clinical psychology wanting to expand its sphere of influence in an historically medically dominated field with the social democratic, utilitarian ethos of a key policy influencer in Richard Layard. This placed psychology and its practitioners in a position of previously unimaginable influence within mental health service development in the NHS, with the opportunity for future mission creep into other areas. But, to return to Cairney (2018), this was largely because the psychological evidence corresponded to the policy reality (i.e., for IAPT, psychology was able to present policy-based evidence, rather than IAPT being drawn from evidence-based policy). As such, its policy influence had material, resource-based advantages in a way that alignment with the service user movement will not, because, it is much more unlikely that service user based evidence is going to align so comfortably with the evidentiary needs of policy makers, psychiatrists or psychologists (and once we move to consider the psy-professions, we are already one degree removed from influen- cing policy processes). So, in order for psychological evidence to be utilised by community stakeholders, it may have to risk being ‘sidelined’ in other forums. This question is as much ethical as scientific and will confront psychologists trying to influence policy with the challenging question, what are the implications of this evidence not for policy but for the communities many of us are paid to serve? As we have argued in this paper, this question is less straightforward than we might like to think.

Received: 30 April 2018 Accepted: 3 August 2018

References

Ali S, Rhodes L, Moreea O, McMillan D, Gilbody S, Leach C, Lucock M, Lutz W, Delgadillo J (2017) How durable is the effect of low intensity CBT for depression and anxiety? Remission rates and relapse in a longitudinal cohort study. Behav Res Ther 94:1–8
BPS (2014) Understanding psychosis and schizophrenia. https://www1.bps.org.uk/ system/files/Public%20files/rep03_understanding_psychosis.pdf Accessed 24 Mar 2018

Cairney P (2016) The politics of evidence-based policy making. Palgrave, London Cairney P (2018) The UK government’s imaginative use of evidence to make

policy. Br Polit https://doi.org/10.1057/s41293-017-0068-2
Cancian M, Slack K, Yang MY (2010) The effect of family income on risk of child maltreatment. Institute for research on poverty: Discussion paper no. 1385-10.

Institute for Research on Poverty

Clark DM (2011) Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: The IAPT experience. Int Rev Psychiatry 23(4):318–327. https://doi.org/10.3109/09540261.2011.606803

Delgadillo J, Asaria M, Ali S, Gilbody S (2015) On poverty, politics and psychology: the socioeconomic gradient of mental healthcare utilisation and outcomes. Br J Psychiatry 1–2 https://doi.org/10.1192/bjp.bp.115.171017

Davies W (2015) The happiness industry: how the government and big business sold us wellbeing. Verso, UK

Farsides T, Sparks P (2015) Buried in bullshit. Psychologist 29(5):368
Fishbeyn B (2015) When ideology trumps evidence: a case for evidence based

health policies. Am J Bioeth 15(3):1–2
McInnes B (2014) The researcher, and so, again, to IAPT. Therapy Today 25

(10):18–24
NHS Digital (2016) Psychological therapies: Annual report on the use of IPAT

services. Health and Social Care Information Centre
NHS Digital (2017) Improving access to psychological therapies (IAPT): Executive

Summary December 2017. Health and Social Care Information Centre
New York Times (2017) England’s Mental Health Experiment: No-Cost Talk Therapy. https://www.nytimes.com/2017/07/24/health/england-mental-

health-treatment-therapy.html Accessed 24 Mar 2018
Perkins A (2015) The Welfare Trait- How state benefits affect personality. Palgrave

Macmillan.
Prinja S (2010) Role of ideas and ideologies in evidence-based health policy. Iran J

Publ Health 39(1):64–69
Rhodes R (2015) Replication- latest twists. Psychologist 29(5):334
Speed E, Taggart D (2012) It’s your problem but you need us to help you fix it: the

paradox at the heart of the IAPT agenda. Asylum Mag Democr Psychiatry 19

(3):23–24
Tonge WL, James DS, Hillam SM (1975) Families without hope: a controlled study

of 33 problem families. Ashford, Headley
Watts J (2016) IAPT and the ideal image in The future of psychological therapy:

from managed care to transformational practice. In: John Lees (Ed.), Rou- tledge, UK

Dr Mike Scott

Jettisoning the CBT Model of Medically Unexplained Symptoms

 

In a just published Editorial in the Journal of Health Psychology MUS and CBT Editorial we have called time on this model. The abstract reads:

The ‘medically unexplained symptoms’ syndrome concept and the cognitive-behavioural treatment model

First Published September 23, 2021 Editorial

The American Psychiatric Association’s, 2013 DSM-5 abandoned the use of the term ‘medically unexplained symptoms’ for non-neurological disorders. In the UK, treatments for various medical illnesses with unexplained aetiology, such as chronic fatigue syndrome, irritable bowel syndrome and fibromyalgia, continue to fall under an MUS umbrella with cognitive behavioural therapy promoted as a primary therapeutic approach. In this editorial, we comment on whether the MUS concept is a viable diagnostic term, the credibility of the cognitive-behavioural MUS treatment model, the necessity of practitioner training and the validity of evidence of effectiveness in routine practice.

Dr Mike Scott

Critiquing IAPT and The Psychologist

The October issue of The Psychologist features a letter of mine and the Editor’s response:

‘In the September issue, Ross Harper – CEO of Limbic, providing AI software for mental healthcare – extolled the virtues of their collaboration with four IAPT services. The supposed gains were all in operational matters, e.g. reduced time for assessment, with no evidence that the AI has made a clinically relevant difference to client’s lives. 

This is merely the most recent example of the biased reporting of The Psychologist with regards to IAPT. I raised these concerns in a 2014 submission, ‘IAPT – The Emperor Has No Clothes’, and the Editor rejected it with the line ‘I also think the topic of IAPT, at this time and in this form, is one that might struggle to truly engage and inform our large and diverse audience’. This response was breathtaking given that IAPT was/is the largest employer of psychologists. 

Fast forward to 2018, and I had published a paper ‘IAPT – The Need for Radical Reform’ in the Journal of Health Psychology, presenting data that of 90 IAPT clients I assessed independently using a standardised diagnostic interview only 10 per cent ‘recovered’ (in the sense that they lost their diagnostic status). This contrasts with IAPT’s claimed 50 per cent recovery rate. The paper has received only a passing mention in the pages of The Psychologist [‘Letters’, Flatt and Lido, April 2021]. This year I wrote a rebuttal of an IAPT inspired paper that was published in the British Journal of Clinical Psychology, ‘Ensuring IAPT Does What It says On The Tin’, but again no mention of this debate in The Psychologist.

In my view the BPS is guilty of a total dereliction of duty to mental health service users in failing to facilitate a critique of IAPT. If psychologists cannot pick out the log in their own eye, how can they pick out the splinter in others? 

Dr Mike Scott 
michaeljscott1@virginmedia.com

Editor’s reply: Funnily enough, we’ve also received strong criticism over the years for being too critical of IAPT! While I stand by my ‘at this time and in this form’, those are ever-shifting considerations and I’m pleased to now be in contact with you about a potential contribution to the magazine’.

 Further to the editor’s reply I have submitted an article ‘Spin In CBT’ see below, alas the Editor said ‘no’ . I am off to a home for the bemused and befuddled.

The Spinning of CBT

 

Michael J Scott, Joan S Crawford and Keith Geraghty

 

There has been a massive expansion of psychological therapy services since the inception of the UK Government’s, Improving Access to Psychological Therapies (IAPT) Service in 2008. Offering principally and allegedly, cognitive behaviour therapy (CBT), by 2023/24 the IAPT Service hopes to see 1.9 million people a year [IAPT Manual, August 2021]. This represents a quarter of the community prevalence of depression and anxiety disorders. The intent of IAPT is clearly laudable, but it is much less clear that it meets the needs of clients? Is it worth the money? Given that the typical IAPT therapist earns £35K a year (twice that of a Care Assistant), and with salary costs reaching over £0.5 billion per year by 2023/24, there is a pressing need for independent audit.

By Services Marking Their Own Homework

The first author was alerted that all may be not well at IAPT’s coalface, when as an Expert Witness to the Court he reviewed 90 cases, treated with alleged CBT, and found a recovery rate i.e loss of diagnostic status, in just 10% of cases, using a standardised diagnostic interview Scott (2018). This applied whether or not service users were treated before or after their personal injury. This ‘tip of the iceberg’ response, contrasts sharply with IAPT’s claimed recovery rate of 50%. Curiously there has been no publicly funded independent audit of IAPT which would help to settle matters.

To Mask A Fault Line In the Provision of Routine Psychological Therapy

There is a fault line in IAPT’s approach which we thought might be rectifiable Scott (2018) [IAPT- The need for radical reform, Journal of Health Psychology] and Scott (2021) [Ensuring IAPT does what it says on the tin. British Journal of Clinical Psychology], but which may in fact make its’ ‘building’ of services inherently unsafe. IAPT declares usage of the ICD-10 code (the World Health Organisation’s labelling system for all disorders). The recent IAPT Manual (August 2021) https://www.england.nhs.uk/wp-content/uploads/2018/06/the-iapt-manual-v5.pdf recommends that IAPT clinicians give at least one code to each client, to characterise their debility. But nowhere in the Manual does it suggest that IAPT clinicians make a diagnosis. An ICD-10 code is only as reliable as the diagnosis made. The Manual claims that NICE Guidelines are based on ICD-10 codes and that IAPT is therefore NICE compliant.  However the treatments recommended by NICE are all diagnosis specific, it follows that if there is no diagnosis there can be no fidelity to a NICE protocol. A key part of IAPT’s narrative is to gloss over that IAPT’s interventions are based, not on diagnosis, but on ‘problem descriptors’. The silent assumptions are that: a) there would be reliable agreement (reliability) between clinicians about what would constitute a client’s main problem and b) there is a body of evidence that a problem descriptor acts as a key to unlock the door to a specific protocol. Further that the specific protocol has been demonstrated to confer an added value, over and above an active placebo, for the chosen problem descriptor. There is an assumption of clinical utility. But there is no empirical evidence for either a) the reliability or b) the clinical utility. Whilst IAPT interventions contain elements of protocols used in randomised controlled trials there is no evidence of fidelity to such protocols i.e of comprehensive coverage of treatment targets for a disorder and matching treatment strategies.

A Pandemic of Spin

 

Spin has been identified in half the abstracts of papers in psychiatry and psychology journals Jellison et al (2020). In this context spin referred to a claim that an experimental treatment was beneficial, despite a statistically nonsignificant difference for the primary outcome or to distract the reader from statistically nonsignificant results.  IAPT claims its sojourn into the treatment of persistent physical symptoms (PPS), such as chronic-fatigue syndrome, is evidence-based, but it is an exemplar of precisely what Jellison et al (2020) identified. Chalder et al (2021) compared the effectiveness of transdiagnostic cognitive behavioural therapy (TDT-CBT) plus standard medical care (SMC) to SMC alone. The primary outcome measure was the Work and Social Adjustment Scale (WSAS). There was no significant difference in outcome on this measure but in the abstract  Chalder et al (2021) proclaim  their intervention ‘may be helpful with a range of PPS’, with an appeal to some outcomes on secondary measures.

But arguably there are other additional markers of spin a) when the primary outcome is not independently assessed b) when the primary outcome is not clinically relevant and c) when there is no prior specification of what would constitute a minimally important difference in the primary outcome measure. In this connection none of the studies used to justify IAPT’s low intensity interventions have involved an independent assessor using a standardised diagnostic interview. For example, the Stress Control (SC) Programme is the most commonly delivered first line group intervention in IAPT Dolan et al (2021). In the SC studies outcome was assessed purely with self-report measures without any guarantee that the measures related to the disorders that the clients were suffering from. Dolan et al (2021) made no attempt to explain a) what a change of X on these measures would mean as opposed to a change in Y and b) whether the changes of scores would be meaningful to a client. The study showed  an effect size difference in outcome between SC and active comparison conditions and passive controls of 0.12-0.15, but this is so small as to be of doubtful clinical significance.  Nevertheless under a heading of ‘Practitioner Points’ they declare ‘SC is appropriate and effective for mild to moderate anxiety and depression’. Dolan et al (2021) found that the SC studies had a mean quality score of 18.21 but fail to mention that this is much lower than the mean score of 27.8 [Ost (2008)] in CBT studies. Ost (2008) commenting on a series of studies that had a mean score of 19.6 declared that this set of studies could not therefore be considered an empirically supported treatment (EST). IAPT does not provide EST’s in their low intensity provision. Further there is no evidence of fidelity to ESTs in the high intensity interventions. Additionally the dosage of therapy routinely delivered in high intensity IAPT therapy falls far short of that advocated in randomised controlled trials of CBT.

The Genesis of Spin

Spin is often related to undeclared conflicts of interest. In the Dolan et al (2021) study all authors declared no conflict of interest. But the corresponding author for the Dolan et al (2021) study is a programme director of IAPT and another of the authors has IAPT involvement. Unfortunately this is not an isolated example, Scott (2021) challenged a similar non-disclosure by these authors earlier this year.

A National Failure to Address Spin

The National Audit Office (NAO) began an investigation into the IAPT service but then stopped it in June 2018 without publication of findings. Following a Freedom of Information request to the NAO, the first author was told in a communication dated February 17th 2020 that the investigation was halted because of variously, the collapse of Carillion and Brexit, with no intention of resuming its’ investigation. Further the NAO response added ‘The investigation was not intended to comment on clinical judgements or the extent to which services meet patient needs’! IAPT has successfully enlisted NHS England, Clinical Commissioning Groups (CCGs), the British Psychological Society (BPS) and the British Association for Behavioural and Cognitive Psychotherapy (BABCP) to proclaim its’ ‘world-beating’ [Dr Claire Murdoch, NHS England Mental Health Director, Health Business August 26TH 2021] status. IAPT is however eminence-based not evidence-based.

The Demise of The Psychologist’s Role

IAPT is the major employer of psychologists, who risk becoming deskilled by the climate change brought about by the Service.  Psychologists tend to stay in IAPT for a few years before heading for the exit to secondary care of private work. This leaves an IAPT workforce bereft of the means of critical appraisal of their work. Staff are ill-equipped to challenge the edicts from on high and disagreement is seen as disloyalty resulting in burn out and worse.

  1. Michael J. Scott, Consultant Psychologist, Liverpool, UK

 

  1. Joan S. Crawford, Counselling Psychologist, Mersey Care NHS Foundation Trust, Chronic Pain Management Service (CPMS), St Helens. https://orcid.org/0000-0001-6400-1158

 

  1. Keith Geraghty, Centre for Primary Care, Division of Health Sciences and Population Health, University of Manchester, UK. https://orcid.org/0000-0001-5060-5022

           

Corresponding author:   Michael J Scott michaeljscott1@virginmedia.com

 

 

 

 

 

Key resources

Chalder, T., et al. (2021). Efficacy of therapist-delivered transdiagnostic CBT for patients with persistent physical symptoms in secondary care: a randomised controlled trial. Psychological Medicine, 1–11. https://doi.org/10.1017/S0033291721001793.

 

Dolan, N., Simmonds-Buckley, M., Kellett, S., Siddell, E., & Delgadillo, J. (2021). Effectiveness of stress control large group psychoeducation for anxiety and depression: Systematic review and meta-analysis. The British journal of clinical psychology60(3), 375–399. https://doi.org/10.1111/bjc.12288

Jellison S, Roberts W, Bowers A, et al. BMJ Evidence-Based Medicine 2020; Evaluation of spin in abstracts of papers in psychiatry and psychology journals  25:178–181.

Scott M. J. (2018). Improving Access to Psychological Therapies (IAPT) – The Need for Radical Reform. Journal of health psychology23(9), 1136–1147. https://doi.org/10.1177/1359105318755264

 

Scott M. J. (2021). Ensuring that the Improving Access to Psychological Therapies (IAPT) programme does what it says on the tin. The British journal of clinical psychology60(1), 38–41. https://doi.org/10.1111/bjc.12264

 

 

 

 

 

 

 

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The Improving Access to Psychological Therapies (IAPT) Service Fails To Make the Case for Its’ High Intensity Therapy

 

 

IAPT claims a 50% recovery rate when comparing Service entry and exit scores. It does so without any differentiation between treatment modality: low intensity CBT, high intensity CBT or the combination. However, a study from Northern Ireland focussing solely on the effectiveness of low intensity CBT also claims a recovery rate of 50% https://www.dropbox.com/s/s32zabv1ffzyn9q/IAPT%20%20and%20N.Ireland%20data.docx?dl=0 [Full paper reproduced below] using just Psychological Wellbeing Practitioners (PWPs). This must raise doubts about whether there is any added value to high intensity CBT. Alternatively IAPT’s way of assessing service effectiveness is seriously flawed. 

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A New Mental Health Service Model for NI: Evaluating the Effectiveness of Low Intensity CBT (LI-CBT) delivered in primary/community care settings

Policy Briefing 8th March 2017

Dr Karen Kirby, Orla McDevitt-Petrovic (MSc), Dr Orla McBride, Prof Mark Shevlin, Dr Donal McAteer, Dr Colin, Gorman, Dr Jamie Murphy (Ulster University).

Knowledge Exchange Seminar Series 2016-17

Abstract

The prevalence of mental health problems in Northern Ireland (NI) is 19%, and this is 25% higher than in England (DHSSPS, 2014). In recent years, there have been extensive consultations, and subsequent recommendations made in NI, in an effort to address this issue and to support an improved infrastructure for the training and development of those working within mental health services (DHSSPS, 2012, 2015). Reform within mental health services in NI has been informed over the past decade by the Bamford review from which two action plans have been proposed (DHSSPS, 2012, 2015). In response to this, researchers at Ulster University wanted to demonstrate an evidence base for the implementation of a new primary care/community based psychological therapies service model in NI, based on the UK ‘Improving Access to Psychological Therapies’ (IAPT) service model. This was informed by the National Institute of Clinical Excellence (NICE) guidelines, which advocates the use of low intensity cognitive behavioural therapy (LI-CBT) for mild to moderate anxiety and depression (NICE 2004a, 2004b). Evidence from IAPT sites suggest that the model is clinically effective (Clark, Layard, Smithies, Richards, Suckling & Wright, 2009) but that the appropriate resourcing of steps one and two is a more cost effective way to manage the high demands placed on health services. Hence, the current study aims to evaluate the effectiveness of implementing an IAPT service model using LI-CBT in primary and community care settings in NI. Two clinically valid routine outcome measures were used, which evaluate every client in every session, with data collection for the first phase of the study taking place between January 2015 and October 2016. Preliminary reliable change outcomes for the pilot cohorts showed recovery rates of 47.9%, improvement rates of 76.7% and deterioration rates of 6%. These findings indicate that the IAPT service model is clinically effective in a NI population. Data collection for the study is continuing between November 2016 and November 2017, using the same outcome measures, and additional follow-up data will also be examined in order to determine if the psychological benefits of interventions are maintained over time. Future analyses will also aim to identify individual and service level factors which potentially impact the effectiveness of the intervention.

Background

The English IAPT initiative

‘Improving Access to Psychological Therapies’ (IAPT) is a large scale initiative which has received substantial government investment in England (Gyani, Shafran, Layard and Clark (2013). It was first implemented in 2007, and aims to improve access to evidenced-based psychological treatments for common mental health difficulties, primarily depression and anxiety (Clark, et al, 2009). ‘Access’ specifically refers to the provision of treatments which embrace utilization, and availability, as well as efficiency and effectiveness. Furthermore, improved access is attributed to equity and to promote a culture of social inclusion and patient centeredness (Gulliford, Hughes & Figeroa-Munoz, 2001).

The IAPT service model is informed by the National Institute of Clinical Excellence (NICE) guidelines, which advocate the use of cognitive behavioural therapy (CBT) in the treatment of anxiety and depression (NICE 2004a, 2004b). Importantly, these guidelines also recommend that psychological interventions are delivered according to a stepped care framework, whereby the most effective, yet least resource-intensive, treatment is delivered first. NICE guidelines recommend that mild to moderate depression and anxiety can be managed effectively using low intensity interventions within primary care and community level settings (DHSSPS, 2005). Low intensity in this case refers to forms of CBT treatment which can be delivered in non-traditional formats (e.g. via telephone/online) and often require less practitioner support in terms of the frequency and duration of sessions. The IAPT workforce delivering these interventions are referred to as psychological wellbeing practitioners (PWP: Richards and Whyte, 2011).

Evidence from UK IAPT sites suggest that low intensity CBT is an effective treatment for mild to moderate depression and anxiety (Clark et al, 2009). Gyani, et al. (2013) examined data from 32 IAPT sites, representing approximately 19,000 clinical cases, and reported that 40% of individuals had reliably recovered and 64% had reliably improved since using the service. Within IAPT services, clients complete the PHQ-9 (measuring depression), and the GAD-7 (measuring anxiety) at each contact. Improvement is determined using a reliable change index whereby six and four indicate reliable change in depression and anxiety respectively. Recovery requires a demonstration of reliable improvement, with final scores below clinical thresholds, on both psychometric measures at the end of treatment.

The IAPT initiative has also been demonstrated to have important cost benefits. The estimated average cost for a low intensity session and course of treatment was £99 and £493 respectively. These estimates are supportive of the originally proposed IAPT programme on cost-benefit grounds (Layard, Clark, Knapp & Mayraz, 2007;

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Radhakrishnan, Hammond, Jones, Watson, McMillan-Shields, & Lafortune, 2013). The rationale for nationwide implementation has also been motivated by the potential economic gains associated with increased productivity and re-employment (Layard et al., 2007)

Mental Health Services in Northern Ireland

The prevalence of mental health problems in Northern Ireland (NI) is 19%, and this is 25% higher than in England (DHSSPS, 2014). Despite the prevalence of mental health difficulties in NI being 25% higher, services in England spend more than double the per capita spend on the provision of support for individuals with mental health difficulties (DHSSPS, 2010; DHSSPS, 2014). In recent years numerous policy documents relating to mental health services in Northern Ireland have been published to address this issue and to support an improved infrastructure for the training and development of those working in mental health services (e.g. Making Life Better 2012-2023, Northern Ireland Public Health Framework 2012; Transforming Your Care, DOH 2011; Health and Wellbeing 2026, DOH 2016). Moreover, reform of mental health services in Northern Ireland has been informed throughout the past decade by the Bamford Review (Bamford, 2006). In 2016, the Department of Health Northern Ireland initiated an evaluation of the 2009-2011 and 2012-2015 Bamford action plans (DHSSPS, 2012, 2015). Preliminary findings highlighted that there remains a need to further promote psychological therapies, to improve access to services in times of crisis, and to improve involvement at the community and voluntary level. Funding reductions are considered to account, in part, for the failure to fully implement Bamford recommendations and best practice initiatives throughout the province. (DHSSPS, 2012, 2015).

The Strategy for the development and implementation of psychological therapy services in Northern Ireland (DHSSPS, 2010) recommended that psychological therapies should be a “core component” within mental health services (pg 49). Recommendations made in regards to strategy implementation indicate that additional investment, in the region of £4.4 million, would be required annually from 2011 within psychological therapies in order to facilitate significant reform.

However, the Bamford Vision acknowledged that further funding would be required for mental health and learning disability services across a 10 to 15-year period, due to historically inadequate investments and the growing need for psychological treatment in NI. Recently reported figures indicate that none of Northern Ireland’s five Health Trusts have met the 13 week waiting time targets for treating individuals with mental health problems during the last three years, and local government already acknowledged the need for a workforce strategy to avoid potential shortfalls such as this (HSCB, 2015). From the perspective of service users and providers, a recent report from Action Mental Health indicated that service users feel they are not treated like people but as problems to be managed. From a systemic perspective, serious concerns were highlighted regarding inadequate funding, fragmentation of services, poor communication and lack of leadership (AMH, 2015).

Overuse of pharmacological interventions

It has been recently reported that that GPs in Northern Ireland prescribe anti-depressant medications at a rate 2.5 times higher than in England and Wales (McClure, 2013). Whilst not disregarding the legacy of the ‘Troubles’, prescription rates were found to be significantly higher than in other UK regions with similar economic profiles and even higher rates of depression, which again points to an issue of potentially inadequate access to non- pharmacological help. In response, and in order to provide GPs with an alternative to medications for common mental health problems, ‘Primary Care talking therapy hubs’ were introduced in NI (HSCB, 2015). The aim of such Hubs is to advocate prevention and early intervention using services including counselling, CBT, group therapy, guided self-help, life coaching and signposting to community services. Hubs in the five Health and Social Care Trusts across the province are still in the process of being established, and there has been recognition from local government that additional hubs with appropriately trained staff are required (HSCB, 2015).

Psychological Therapies in Primary Care

Although the efficacy of early interventions such as low intensity cognitive behavioural therapy (LI-CBT) is most strongly evidenced with depression and anxiety, and although such approaches are shown to save money in the long term (Layard et al., 2007), a stepped care model has not yet been fully established in NI (Blane, Williams, Morrison, Wilson and Mercer, 2014). Psychological therapy service provision in NI has tended to focus on the more complex end of the spectrum of mental health difficulties, and consequently, educational and professional training has similarly concentrated largely on individuals working at these levels. In 2013, the Northern Ireland Mental Health Services Threshold Criteria acknowledged that low intensity therapists working at stepped care

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levels one and two, including those delivering LI-CBT, are crucial for the establishment of an effective stepped care approach to psychological therapy provision in the province (MHSTC, 2013).

Training of Psychological Wellbeing Practitioners in Northern Ireland

In light of the mental health problems faced by large numbers of the population in NI, and in recognition of the need for an appropriately skilled and experienced workforce to fill the aforementioned gap in service provision, Ulster University developed accredited training in evidence-based low intensity interventions for common mental health difficulties. Since 2014, this has facilitated the training of British Psychological Society accredited Psychological Wellbeing Practitioners (PWPs), who deliver low intensity cognitive behavioural therapy interventions to individuals within Primary/Community Care level services throughout training.

Aims and Objectives

Considering the evidence presented above, it is clear that the current provision of psychological therapies at the Primary/Community Care Level in NI is in its early stages of development, with few empirical evaluations to date of the effectiveness of treatment approaches at this level. Indeed, the recent DoH (2016) indicated that the improvement of access to psychological services has been wholly inadequate and significant funding is required to match that which is being offered in England. Hence, there is a need to provide evidence of a service model that works, and can be implemented effectively in NI. The main objective of the current pilot study is to present the preliminary findings of an evaluation of PWPs providing LI-CBT for common mental health difficulties working directly with the newly established ‘Primary care Talking Therapies Hubs’ and community care settings in an NI context. It was predicted that following a course of LI-CBT there would be a reduction in PHQ-9 and GAD-7 scores to normal range below clinical thresholds, and that these findings would be in keeping with existing IAPT UK outcomes, thereby providing initial evidence that the IAPT service model is effective in a Northern Ireland context.

Method

This was a prospective study following a cohort of participants from baseline (before commencement of therapy), through the course of LI-CBT weekly treatment (1-11) sessions, and ‘follow-up’ (4 months post-discharge). This study is limited to examining changes in psychological status in participants before and after therapy; the follow- up analysis is part of an on-going project.

Sample

Trainee PWPs consisted of students on the MSc applied psychology course at Ulster University, which facilitated clinical skills, training, placements and supervision. Data from a total of 199 patients who attended a trainee PWP within the 2015 and 2016 cohorts was collected. (see figure 1). In keeping with IAPT recommendations (Gyani et al., 2013), the clinical outcomes reported here are related only to clients meeting “caseness” criteria. This required at least two contacts with a PWP as pre and post treatment scores cannot be collected based on a single initial session. A ‘case’ client must also have scored above the clinical thresholds on at least one of the measures at assessment, more specifically this refers to scores of 10 and/or 7 or above on the PHQ-9 and GAD-7 respectively. 165 clients were identified as “case” and 35 were identified as “non-case” prior to analysis, in accordance with this IAPT “caseness” criteria. Of the clients fitting caseness criteria, there were 105 females and 60 males. Ages ranged from 18 to 77, with a mean age of 39. 55% of patients were treated in community settings, 18% in a GP practice, and 27% at primary care services psychological therapies within a Northern Ireland NHS Trust.

Measures

As per IAPT service protocol, each client at each contact completed two routine outcome measures.

The Patient Health Questionnaire (PHQ-9) was used to measure the severity of depressive symptoms. This is a nine-item standardised measure which has been validated in a UK depressed population (Cameron, Crawford, Lawton & Reid, 2008). The scores range from 0 to 27, with a score of ten or more being the threshold to identify clinically relevant depressive symptoms (Kroneke, Spitzer & Williams, 2001).

The General Anxiety Disorder Questionnaire (GAD-7) has also been determined to have good psychometric properties having been validated in U.S. populations. The scores range from 0 to 21 and a score of eight or more

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being the threshold to identify clinically relevant general anxiety disorder (Kroneke, Spitzer, Williams, Monahan & Lowe, 2007).

Trainee PWPs consisted of students on the MSc applied psychology course at Ulster University, which facilitated clinical skills, training, placements and supervision. Data from a total of 199 patients who attended a trainee PWP within the 2015 and 2016 cohorts was collected. In keeping with IAPT recommendations (Gyani et al., 2013), the clinical outcomes reported here are related only to clients meeting “caseness” criteria. This required at least two contacts with a PWP as pre and post treatment scores cannot be collected based on a single initial session.

A ‘case’ client must also have scored above the clinical thresholds on at least one of the measures at assessment; more specifically, this refers to scores of 10 or above on the PHQ-9 and/or 8 or above on the GAD-7. 165 clients were identified as “case” and 34 were identified as “non-case” prior to analysis, in accordance with the IAPT “caseness” criteria. Of the clients fitting caseness criteria, there were 105 females and 60 males. Ages ranged from 18 to 77, with a mean age of 39. 55% of patients were treated in community settings, 18% in a GP practice, and 27% at primary care psychological therapies service within a Northern Ireland NHS Trust.

Reliable change rates

The Reliable Change Index (Jacobson & Truax, 1991) is an appropriate way of assessing deterioration or improvement in anxiety and depression symptoms, as it allows one to determine whether an increase or decrease in psychometric scores from baseline to post-treatment exceeds the measurement error of the relevant scale, and thereby can be considered statistically reliable. In keeping with existing IAPT evaluations (Gyani et al., 2013), a reduction or increase of six or more points on the PHQ-9 and a reduction or increase of four or more points on the GAD-7 have been determined as the thresholds for reliable change in depression and anxiety symptoms respectively. Clients are considered to have ‘reliably improved’ if either of their measure scores reliably decreased and the score for the other measure either remained the same or did not reliably deteriorate. Clients are considered to have ‘reliably deteriorated’ if either measure score reliably increased, or the other score either also increased or did not reliably improve. A reliable recovery index was also used in line with existing IAPT studies (Gyani et al., 2013). Clients are considered to be ‘reliably recovered’ if they scored above the clinical threshold on at least one psychometric measure at assessment interview, showed reliable improvement during the course of treatment, and scored below clinical thresholds on both the PHQ-9 and GAD-7 at the point of treatment completion. For example:

  •   A case client with the following scores would have demonstrated reliable improvement: baseline PHQ-9 (13), baseline GAD-7 (9), final PHQ-9 (7), final GAD-7 (8).

  •   A case client with the following scores would have demonstrated reliable deterioration: baseline PHQ-9 (14), baseline GAD-7 (10), final PHQ-9 (9), final GAD-7 (14).

  •   A case client with the following scores would have demonstrated reliable recovery: baseline PHQ-9 (15), baseline GAD-7 (8), final PHQ-9 (8), final GAD-7 (5)

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Results

A total of 199 participants sought access to the service. Of these, 198 were assessed and of these 178 attended a second session at least; the rate of uptake of LICBT was therefore 89.4%. Overall, 47.9% of patients who met caseness criteria demonstrated reliable recovery. 76.7% of these patients demonstrated reliable improvement, and 6.1% demonstrated reliable deterioration (see table 1).

Table 1: Frequencies and percentages of reliable recovery, improvement and deterioration rates for LICBT patients meeting caseness criteria for cohorts 2014/15 and 2015/16.

page6image14839232

*Caseness criteria met (n= 165)

page6image14839424 page6image14839616 page6image14839808 page6image17089632 page6image17093664

Yes
No Missing

Reliable Improvement demonstrated

125 (77%) 38 (23%) 2 (1.2%)

Reliable Deterioration demonstrated

10 (6%) 153 (94%) 2 (1.2%)

Reliable Recovery demonstrated

78 (48%) 85 (52%) 2 (1.2%)

page6image17096688

*At least 2 sessions attended and above clinical thresholds on one or both measures at baseline = caseness

Discussion

Initial Northern Ireland outcomes: Clinical effectiveness

Findings from the current study are in keeping with outcomes from UK IAPT sites including the previously reported 2015/16 outcomes (HSC, 2016). More specifically, when NI reliable change rates are compared directly with the most recently published IAPT UK outcomes, recovery rates are 47.9% and 46.3% respectively. Improvement rates are 76.7% and 62.2% for NI and England respectively (HSC, 2016). These preliminary results provide initial evidence that low intensity cognitive behavioural therapy is an effective treatment for mild to moderate level mental health difficulties in NI. As reported earlier the prevalence of mental difficulties in NI is 25% higher than in England (DHSSPS, 2014). More explicitly, the Northern Ireland Health Survey (2014/15) reported that 19% of respondents exhibited symptoms of a potential mental health problem (Bell & Scarlett, 2015). Assuming this population was suitable for LI-CBT, it may be estimated based on the current findings that prevalence could be reduced to 4.4% with reference to improvement rates and 9.9% with reference to recovery rates.

Cost benefits: increasing reemployment and productivity

Furthermore, research also indicates that 22% of individuals in NI live in poverty (Bell & Scarlet, 2015). Indeed, in Northern Ireland, the prevalence of mental health difficulties is doubled (30%) for those in the most deprived areas, when compared with those in areas of less deprivation (15%) (Bell & Scarlett, 2015). It is estimated that recent public cuts have affected Northern Ireland in a particularly detrimental way, given that the region relies on public spending for 62.2% of its output, compared to 39.8% in the rest of the UK.

Compared with other regions of the UK, NI has the highest proportion of adults not in work (28.4%). More precisely, this is 5% higher than the UK average (O’Neill, McGregor & Merkur, 2012). Absenteeism is heavily attributed to mental health difficulties, more specifically accounting for 31.9% of all lost days, and 39.1% of long- term sick leave (NISRA, 2015). The economic gains directly associated with IAPT in England in the first three years include almost 45,000 individuals moving off benefits (Clark, 2011). As the IAPT model has been applied to mental health clients in the current study, the LI-CBT interventions used here could have a similar impact on individuals moving off benefits and returning to work in NI. The findings of the current study can therefore be

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tentatively applied to infer that such evidence based interventions for common mental health problems could reduce rates of absenteeism in the province. Using the NISRA figures, days lost through mental health issues could therefore be reduced to 7.43% as per improvement rates found in the current study, and 16.7% as per recovery rates. However, this would need to be formally evaluated, and hence our future research recommendations are to assess prospective employment/benefit rates for the 2016/2017 cohort.

Further expansion of the English IAPT initiative has been recommended as a step to achieving better access to mental health services by 2020 (DOH, 2014). Investment in health care is important for both socioeconomic and ethical reasons, but has also been emphasised in order to counteract perceived “institutional bias”. More resources are dedicated to physical healthcare even though mental ill health can accrue an annual societal cost of up to 100 billion (DOH, 2014).

Moreover, Layard and Clark (2015) have recently reported on reasons why more psychological therapy would cost nothing. In the majority of wealthy countries, approximately 1% of the working age population are on benefits due to depression or anxiety. This costs the UK government £650 more per month per person, compared with if they were not receiving these payments. If a minimum of just 4% of this patient population worked for just one more month following treatment, the actual cost of treatment would be fully repaid. The argument to expand service provision is therefore thoroughly justified.

Adhering to the evidence base: Delivering the right treatment, at the right time, in the right place

As outlined earlier, the IAPT service model is informed by evidence based clinical guidelines. Our findings support these NICE guidelines in a NI context, which advocate the use of cognitive behavioural therapy for depression and anxiety. NICE assemble a panel of experts made up of clinicians, researchers and consumers who carefully review the available evidence base on the optimum treatments for each physical and mental health problem. In 2004, NICE carried out systematic reviews of research investigating the effectiveness of interventions for depression and anxiety disorders. The resultant clinical guidelines advocate the provision of specific kinds of cognitive behavioural therapy (CBT) for depression and anxiety disorders (NICE, 2004). Crucially, cognitive behavioural therapy is considered to be more effective than medication given that it reduces the likelihood of relapse by at least 50%, and moreover, the vast majority of patients prefer it to a psychological treatment (McHugh, Whitton, Peckham, Welge and Otto, 2013).

As previously outlined, NICE guidelines further recommend that mild to moderate depression and anxiety can be managed effectively using low intensity interventions within primary care level settings (DSSPS, 2005). Furthermore, low intensity interventions improve the flexibility, capacity and responsiveness of the relevant services while increasing patient-choice, and enhancing service cost-effectiveness (Bennett-Levy et al., 2012).

Conclusion

Currently, the mental health service framework in NI does not formally apply this NICE evidence, which has also been highlighted in the recent Evaluation of the Bamford Action Plans (DoH, 2016). Our findings indicate that reliable recovery and improvement have been demonstrated for clients in NI who have presented with common mental health difficulties. Indeed, LI-CBT interventions (provided by PWPs) provides the only evidence base to date in NI for treating anxiety and depression at stepped care levels 1-3. Additionally, the Bamford evaluation highlighted a need to further promote psychological therapies, to improve access to services in times of crisis, and to improve involvement at the community and voluntary level (DOH, 2016; Betts &Thompson, 2017). Our initial findings indicate that PWP’s have addressed this need.

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Recommendations and plans for future low intensity CBT research in Northern Ireland

Clinical Policy Recommendations:

  •   Whilst the findings of this study are preliminary, the current pilot offers a potential solution to addressing the need for evidence-based treatment and suggests that low intensity CBT (provided by accredited PWPs), is a clinical and cost-effective intervention, as well as being an effective service model within primary and community care settings in NI (stepped care 1-3).

  •   Therefore, our recommendation to practice and policy implementation, is that in order to assist the people of NI to gain access to appropriate, clinical and cost effective psychological interventions at steps 1-3, a province-wide PWP service (embedded within the talking therapy hubs and GP practices) needs to be fully established and adequately funded. This could potentially prevent more complex mental health issues through the use of early intervention and quicker access to services with reduced waiting times, and by enabling service users to access the right treatment in the right place at the right time.

  •   Indeed, some recent recommendations made by Sands (2017) have suggested the placing of mental health practitioners, offering the appropriate level of CBT, in every GP practice in NI. We are suggesting that PWP’s can be that ‘mental health practitioner’, who are fit for purpose and fit for the future of NI mental health services.

    Research recommendations:

  •   The collection of patient data and routine outcome measures is continuing at pre-treatment, post treatment and follow up points. In this study future analyses will focus on this larger sample of all previous, current and future cohorts combined. Reliable recovery, improvement and deterioration rates will be produced.

  •   Previous IAPT studies have determined that many of the psychological benefits resulting from interventions had been maintained (Clark et al., 2009). In order to produce comparative data regarding longer-term effectiveness, future N. Ireland research will also examine data collected from clients at a four month follow-up point after discharge from the service.

  •   In order to test for individual differences in treatment effect, a series of latent growth curve models will be specified and tested in order to determine if there are different rates of change for unobservable sub- populations, and to identify individual or service level variables which potentially increase or reduce the effectiveness of the intervention.

  •   Furthermore, data on employment statuses and medication usage pre and post treatment will be scrutinised. Increasingly, governments are driven by the recognition of the huge economic and social costs of high prevalence disorders, and so we need future research to evaluate cost effectiveness in order to inform future service design and planning. Randomised controlled trials facilitating a comparison of service models may also provide further evidence for the effectiveness of the IAPT model in a Northern Ireland context.

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References

Bamford, D. (2006). The Bamford review of mental health and learning disability (Northern Ireland).

Bell, C., & Scarlett, M. (2015). Health Survey Northern Ireland: First Results 2014/15.

Bennett-Levy, J. E., Butler, G. E., Fennell, M. E., Hackman, A. E., Mueller, M. E., & Westbrook, D. E. (2004). Oxford guide to behavioural experiments in cognitive therapy. Oxford University Press.

Betts, J and Thompson, J (2017). Mental Health in Northern Ireland: Overview, Strategies, Policies, Care Pathways, CAMHS and Barriers to Accessing Services. Research and Information Service Research Paper. Northern Ireland Assembly.

Blane, D. N., Williams, C., Morrison, J., Wilson, A., & Mercer, S. (2014). Psychological therapies in primary care: a progress report.

Cameron, I. M., Crawford, J. R., Lawton, K., & Reid, I. C. (2008). Psychometric comparison of PHQ-9 and HADS for measuring depression severity in primary care. Br J Gen Pract, 58(546), 32-36.

Clark, D. M. (2011). Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: the IAPT experience. International Review of Psychiatry, 23(4), 318-327.

Clark, D. M., Layard, R., Smithies, R., Richards, D. A., Suckling, R., & Wright, B. (2009). Improving access to psychological therapy: Initial evaluation of two UK demonstration sites. Behaviour research and therapy, 47(11), 910-920.

Department of Health and NHS (2014). Achieving Better Access to Mental Health Services by 2020. Department of Health Social Sciences and Public Safety (2014). Bamford monitoring report.

Department of Health Social Sciences and Public Safety (2015) Delivering the Bamford vision: The Response of the Northern Ireland Executive to the Bamford review of Mental Health and Disability Action Plan 2012-2015.

Department of Health Social Sciences and Public Safety: Integrated Projects Unit (2012) Evaluation of the Bamford action plan.

Department of Health SS, AND Public Safety. IAPT outline specification: Improving Access To Psychological Therapies (IAPT) 2005.

Department of Health, Social Services and Public Safety. A strategy for the development of psychological therapies services. Northern Ireland: Department of Health Social Services and Public Safety (2010).

Department of Health, Social Services and Public Safety. Making Life Better: A whole system strategic framework for public health 2013-2023. Department of Health, social Services and Public Safety: Belfast. (2014).

Department of Health, Social Services and Public Safety. Reshaping the System: Implications for Norther Ireland’s Health and Social Care Services of the 2010 Spending Review (McKinsey Report). Belfast: Belfast. (2010).

Gulliford, M., Hughes, D., Figeroa-Munoz, J., & Guy’s, King’s and St Thomas’ School of Medicine, London (United Kingdom). Public Health and Health Services Research Group;. (2001). Access to Health Care: Report of a Scoping Exercise for the National Co-ordinating Centre for NHS Service Delivery and Organisation R and D (NCCSDO) 26 February 2001 (with Minor Amendments August 2001). Guy’s, King’s and St Thomas’ School of Medicine, Public Health and Health Services Research Group.

Gyani, A., Shafran, R., Layard, R., & Clark, D. M. (2013). Enhancing recovery rates: lessons from year one of IAPT. Behaviour Research and Therapy, 51(9), 597-606.

Health and Social Care Board (2014) You In Mind. Mental Healthcare Pathway.
Health and Social Care Board (2015). Introducing Primary Care Talking Therapy and Well-being Hubs.

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Health and Social Care Information Centre (2016), Psychological Therapies, Annual Report on the use of IPAT services.

Jacobson, N. S., & Truax, P. (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of consulting and clinical psychology, 59(1), 12.

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The Phq‐9. Journal of general internal medicine, 16(9), 606- 613.

Kroenke, K., Spitzer, R. L., Williams, J. B., Monahan, P. O., & Lö we, B. (2007). Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Annals of internal medicine, 146(5), 317-325.

Layard, R., Clark, D., Knapp, M., & Mayraz, G. (2007). Annex D: Cost-benefit analysis of psychological therapy. Department of health Improving Access to Psychological Therapies (IAPT) programme: An outline business case for the national rollout of local psychological therapy services. London: Department of Health.

Layard, R., & Clark, D. M. (2015). Why more psychological therapy would cost nothing. Frontiers in psychology, 6, 1713.

McHugh, R. K., Whitton, S. W., Peckham, A. D., Welge, J. A., & Otto, M. W. (2013). Patient preference for psychological vs. pharmacological treatment of psychiatric disorders: a meta-analytic review. The Journal of clinical psychiatry, 74(6), 595.

National Audit Office (NAO). Healthcare across the UK: a comparison of the NHS in England, Scotland, Wales and Northern Ireland. London: TSO. (2012-2013).

National Institute for Clinical Excellence, & Britain, G. (2004). Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. National Institute for Clinical Excellence.

National Collaborating Centre for Mental Health. (2004). Depression: management of depression in primary and secondary care. London: National Institute for Clinical Excellence.

NISRA (2015). Sickness absence in the Northern Ireland Civil Service 2014/15. Department of Finance and Personnel. Belfast.

O’Neill,C, McGregor, P., & Merkur, S. (2012). United Kingdom (Northern Ireland). Health System Review. Health Systems in Transition, 14(10).

Radhakrishnan, M., Hammond, G., Jones, P. B., Watson, A., McMillan-Shields, F., & Lafortune, L. (2013). Cost of improving Access to Psychological Therapies (IAPT) programme: an analysis of cost of session, treatment and recovery in selected Primary Care Trusts in the East of England region. Behaviour research and therapy, 51(1), 37-45.

Richards DA, Whyte M. Reach Out: National programme student materials to support the training and for Psychological Wellbeing Practitioners delivering low intensity interventions. UK: Rethink Mental Illness, 2011.

Sands, Louise (2017). RCGP Associate Director – Policy Reform seminar on improving mental health provision in NI, 17th Jan 2017), as cited in Betts, J and Thompson, J (2017). Mental Health in Northern Ireland: Overview, Strategies, Policies, Care Pathways, CAMHS and Barriers to Accessing Services. Research and Information Service Research Paper. Northern Ireland Assembly

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The Damaging Consequences of Not Offering The Best Mental Health Treatment Initially

many will vote with their feet when it comes to further treatment from the same source. Stepped care is the treatment model adopted by the UK Government’s Improving Access to Psychological Therapies (IAPT) Programme. A third (34%) of those who have low intensity therapy are stepped up to high intensity city, according to the IAPT Manual 2021, but the Manual cautions there is considerable local variation in this figure. The question is why? This does not sound like clients following well-defined pathways. As far as I can ascertain IAPT does not publish a recovery rate from low intensity alone, so it is not known what proportion haemorrhage from low intensity.  IAPT is the only show in Town for most people so it is not surprising that when treatment fails some return. For every 2 people referred to IAPT 1 person is attending for between their second and tenth plus courses of treatment – a revolving door. [Following a Freedom of Information Request from Dr Elisabeth Cotton in 2018, it appears that 1.5 million people were referred to IAPT between 2 and 10 or more occasions in a 6 year period (2012-2018), with 3.2 million people referred just once].

 

 

What is going on here? NHS England is replete with the following luminaries according to the IAPT Manual (2021), so it is no surprise that there has been no publicly funded independent audit of the Service:

Current NHS England team

Sarah Holloway, Head of Mental Health, NHS England
Xanthe Townend, Programme Lead – IAPT & Dementia, NHS England

David M. Clark, Professor and Chair of Experimental Psychology, University of Oxford; National Clinical and Informatics Adviser for IAPT

Adrian Whittington, National Lead for Psychological Professions, NHSE/I and HEE; IAPT National Clinical Advisor: Education

Jullie Tran Graham, Senior IAPT Programme Manager
Hayley Matthews, IAPT Programme Manager, NHS England Andrew Armitage, IAPT Senior Project Manager, NHS England Sarah Wood, IAPT Project Manager, NHS England

 It appears common sense for IAPT to offer the least costly service first e.g computer assisted therapy and then progress clients to the more costly face to face service if the minimalist intervention has not worked. But IAPT have borrowed from medical care a modus operandi that is not fit for purpose in mental health. For example there is evidence that for some with back pain, physiotherapy will resolve  problems and is the sensible first line treatment, with progression to the costly surgical interventions if physiotherapy does not suffice. But low intensity psychological therapy does not have the evidence base of physiotherapy. This opens up the likelihood that LI will fail to return the client to their best functioning.  Approx a third of clients (37%) receive low intensity only and a third (29%) high intensity only.

 

The mental health clients take on a failed  first line treatment is likely to involve personalisation e.g  ‘I am stupid, couldn’t quite get what was being asked to do’ and arbitrary inferences e.g ‘I shouldn’t have expected anything would work with me, just my luck’. This is quite different to how most people would likely respond to a failed first line physical intervention. For mental health treatment it may be the the best treatment should be provided first. At a minimum clients should be informed that they are consenting to what is known to be second best.

 

Dr Mike Scott

 

Decrypting the Improving Access to Psychological Therapies (IAPT) Code

IAPT communications have an agenda, their focus is on persuading their source of revenue, local Clinical Commissioning Groups (CCGs) to expand funding, to cover staffing costs of £0.5billion by 2024.  To achieve this goal it uses language that is familiar to the GPs that comprise CCGs, ‘NICE compliant’, ‘recovery’ and claiming a comparability of outcome to those in randomised controlled trials. But CCG’s are themselves under orders from NHS England, who have never critically appraised IAPT’s claims.

The secret to breaking the IAPT Code, is strangely its’ use of the ICD-10 code (the World Health Organisation’s labelling system for all disorders). The recent IAPT Manual (August 2021) https://www.england.nhs.uk/wp-content/uploads/2018/06/the-iapt-manual-v5.pdf recommends that IAPT clinicians give at least one code to each client, to characterise their debility. But nowhere in the Manual does it suggest that IAPT clinicians make a diagnosis. An ICD-10 code is only as reliable as the diagnosis made. The Manual claims that NICE Guidelines are based on ICD-10 codes and that IAPT is therefore NICE compliant.  However the treatments recommended by NICE are all diagnosis specific, it follows that if there is no diagnosis there can be no fidelity to a NICE protocol. A key part of IAPT’s code is to gloss over that IAPT’s interventions are based, not on diagnosis but on ‘problem descriptors’. The silent assumptions are that:

a) there would be reliable agreement (reliability) between clinicians about what would constitute a clients main problem and

b) there is a body of evidence that a problem descriptor acts as a key to unlock the door to a specific protocol. Further that the specific protocol has been demonstrated to confer an added value, over and above an active placebo, for the chosen problem descriptor. There is an assumption of clinical utility.

But there is no empirical evidence for either a) the reliability or b) the clinical utility. 

IAPT operates its’ own coding device, akin to the Enigma machine used by the Germans in World War 2, and it has as a result ill-served millions. NHS England and CCG’s have totally failed to recognise its’ operation, believing instead IAPT’s public broadcasts e.g a 50% recovery rate, when independent assessment indicates a 10% recovery rate Scott (2018) https://doi.org/10.1177%2F1359105318755264.

Dr Mike Scott