Clinical Commissioning Groups (CCG’s) Incredibly Naive Re: IAPT

CCG’s are rubber stamping the funding of IAPT services, without questioning the alleged 50% recovery rate for depression and the anxiety disorders. But CCG’s would never give approval to the dissemination of a psychotropic drug based solely on the manufacturer’s claim. It seems that GP’s on CCG’s are too busy to critically appraise IAPT’s claim.  CCG members need to ask why £1bn has been spent on IAPT services that have never been independently evaluated using a rigorous methodology.  My own, by no means definitive study of 90 consecutive attenders at IAPT suggests a 10% recovery rate [ the paper ‘IAPT The Need for Radical Reform’ can be accessed by selecting below and right clicking https://connection.sagepub.com/blog/psychology/2018/02/07/on-sage-insight-improving-access-to-psychological-therapies-iapt-the-need-for-radical-reform/].  CCG’s are like the Titanic, heading towards an iceberg, on board are not only depressed and anxiety disorders passengers but a recent cohort of those with long term physical health conditions and medically unexplained symptoms:

 

 

Via my MP, Maria Eagle I put the following questions to the Liverpool CCG, (one of the CCGs covering the IAPT clients I examined in the North West) and their response dated March 6th 2018 was as follows:

Question 1.

 

Are the CCG aware that the recovery rate in the IAPT Service they fund is just 10% (far short of the 50% recovery rate targeted by Alan Johnson, then Labour Minister in 2007 when the service was set up).

 

Response 1.

 

Latest local data indicates that the current recovery rate for the service stands at 50%, targets for access and recovery are under regular review with performance reported to NHS England and published nationally and through LCCG Governing Body papers.

 

Question 2.

 

What, if any independent data do the CCG use in assessing the IAPT Service? Response 2.

All IAPT services must assess their performance using nationally mandated measures contained within the IAPT Minimum Data Set (v1.5). Information on these measures and the outcomes achieved by IAPT services can be obtained from NHS Digital.

 

Question 3.

 

Why have the CCG never asked IAPT service users their opinion of the service? Response 3.

All IAPT services routinely ask every IAPT service user their opinion of the services using 2 measures, the Patient Experience Questionnaire (Assessment) and the Patient Experience Questionnaire (Treatment). Information on these measures and the patient satisfaction levels achieved by IAPT services can be obtained from NHS Digital.

 

Question 4.

 

Why do the CCG consider it acceptable to continue to fund a service, were assessments are conducted by telephone by the least experienced and qualified staff? Are they supporting a double standard for physical and mental health?

 

Response 4.

 

LCCG has commissioned a service in line with NICE guidance both in terms of accessibility and responsiveness, but also the required skills of staff employed by the service.

 

Question 5.

 

What steps will the CCG take to ensure that evidence based treatment takes place in IAPT? Response 5.

All treatment provided by Talk Liverpool conforms to the following NICE Guidelines which lay out the evidence based therapies that should be offered for disorders of anxiety and depression:

 

NICE Guidance for depression in Adults (CG90)

NICE Guidance for Depression in adults with a chronic physical health problem (CG91) NICE Guidance for Common Mental Health Problems (CG123)

NICE Guidance for Generalised Anxiety Disorder and Panic Disorder in Adults (CG113) NICE Guidance for Obsessive Compulsive Disorder and Body Dysmorphic Disorder in Adults (CG31)

NICE Guidance for Post-Traumatic Stress Disorder (CG26) All the above can be accessed through;

https://www.nice.org.uk Question 6.

How will the CCG ensure that GPs are given comprehensive data on the functioning of their patients? Currently data is supplied to GPs on less than half of patents and purely in the form of psychometric test results, there are no ‘gold standard’ diagnostic assessments conducted at all. How will the CCG remedy that IAPT workers do not know what they are treating?

 

Response 6.

 

GPs are informed of the outcome of all their patients’ therapy episodes with Talk Liverpool. This includes both psychometric scores and clinical information. With regard to “gold standard diagnostic assessments”, the IAPT service is a treatment service and not a formal diagnostic service. Talk Liverpool provide problem descriptors (and not formal diagnoses) as mandated by the IAPT Dataset V1.5 set out by NHS England, using the nationally mandated psychometric tests (details of which can be found in the IAPT Data Handbook published by NHS England).

 

Links:

 

http://content.digital.nhs.uk/iapt

 

http://ipnosis .postle.net/PDFS/iaptoutcomestoolkit2008november(2).pdf

 

Further information relating to IAPT nationally can be obtained through the National Collaborating Centre for Mental Health and NHS England who have recently published the IAPT Manual which outlines the model that all IAPT services should follow (including some of the procedures implemented by Talk Liverpool including some outlined in the responses given above).

 

Links:

 

http://www.rcpsych.ac.uk/workinpsychiatry/nccmh/mentalhealthcarepathways/improvingac cess.aspx

 

https://www.york.ac.uk/healthsciences/pc-mis/newsarticles/lAPT%20Manual 30OCT17.pdf

 

 

I hope that you and Dr Scott this information helpful.

Yours sincerely

 

Ian Davies

Chief Operating Officer

 

Liverpool CCG show no evidence of having bothered to read my analysis of 90 cases, and have not answered my questions, they have simply acted as the mouthpiece for IAPT.

 

Dr Mike Scott

National Audit Office Not Publishing Its’ IAPT Investigation?

Whatever happened to transparency and accountability! Last year the NAO invited the public to make submissions for its’ IAPT investigation, but it seems a letter from the NAO dated February 14th 2018  obtained under Freedom of Information (FOI) by a Dr Elizabeth Cotton states ‘you requested information …. that relates to the decision not to make the report publicly available  … correspondence and any documents sent by the NAO to the UK health bodies involved that outline the key findings of the inquiry…. The NAO is still drafting its findings and these have not been communicated to any of the health bodies’.

 

 

Under the FOI there is an exchange of e-mails between NAO and NHS England, one from the NAO dated June 28th 2017 is titled ‘NAO investigation into the integrity of IAPT performance data’ and strangely states ‘we have not yet decided for definite whether we will publish a report’.  I made a submission to the NAO on July 25th 2017 and I, like all those submitting evidence which ran to Autumn 2017, would have assumed a report would be published, otherwise they might have considered it a waste of energy!

I have e-mailed the NAO and await a reply.

 

Dr Mike Scott

‘IAPT -The Need for Radical Reform’ 3 Commentaries

The Journal of Health Psychology has just published the 1st of 3 Commentaries on my paper ‘IAPT- The Need for Radical Reform’ https://connection.sagepub.com/blog/psychology/2018/02/07/on-sage-insight-improving-access-to-psychological-therapies-iapt-the-need-for-radical-reform/ , the other 2 commentaries will be published online in the next week or two. I will be writing a commentary on the commentaries.  The 1st of the Commentaries is by Sami Tamimi (see below):

‘The diagnosis is correct, but National Institute of Health and Care Excellence guidelines are part of the problem not the solution’

Mike Scott’s study provides data demonstrating that the national Improving Access to Psychological Therapies project is not leading to improved outcomes or value for money. I present further data from both the adult and children and young people’s versions of Improving Access to Psychological Therapies that lends supports to this conclusion. However, while Scott argues in favour of better compliance with National Institute of Health and Care Excellence guidelines and greater model expertise, I argue that it is this ‘technical’ focus that is part of the problem not the solution.

1Lincolnshire Partnership NHS Foundation Trust, UK
2Health Education England, UK
3University of Lincoln, UK
Corresponding author:
Sami Timimi, Lincolnshire Partnership NHS Foundation
Trust, Trust Headquarters, Lincoln LN1 1FS, UK.
Email: stimimi@talk21.com

Interesting that similar findings in Children and Young Person’s IAPT.

Dr Mike Scott

 

 

Manchester Arena Bombing – The Young and Most Debilitated Poorly Served?

Young people effected by the bombing are having to wait 7-8 months for CAMHS services. The most debilitated adults have sought private counselling or been placed on a CBT waiting list.  These findings are from the Kerslake report on Services response to the Manchester bombing published last week. Worryingly there is no indication that evidence based CBT has yet been made available. This is not to say that most people have not been grateful for the assistance they have had to date, but this is not unexpected as only a significant minority of trauma victims suffer long term debility.

 

 

 

The following are the psychological abstracts from the report:

2.27. Feedback about the NHS Manchester Resilience Hub (established after the attack

to coordinate the care and support for children, young people and adults whose

mental health has been affected by the attack wherever they may live) was largely

positive, although many commented they would have liked something sooner.

Participants appreciated the three-monthly contacts from the Hub and felt

reassured that someone was there for them.

 

“I think the services set up to help those struggling with their mental health

following this event are great too and I feel happy knowing there is always

someone I can talk to if I need to.”

 

“I do however feel that there is a lack of counselling for young people.”

“The counselling support provided in the hospital did not appear to have the skill

level or approach for this type of situation. The counsellor was super-intrusive

coming into the room at 7am.”

 

“I contacted the Resilience Hub and both me and my daughter filled out the

questionnaire. Someone contacted us straight away and felt that my daughter

needed further support, which was arranged quickly. I felt there was lots of

support available. I also felt it helpful that the Hub were going to keep sending

questionnaires every three months to check how people are doing.”

 

“My son was referred for counselling through the Manchester Resilience Hub and

is on a waiting list for CBT as they feel he may have Post-Traumatic Stress

Disorder. The counsellors from Reflections in Oldham are brilliant.”

 

“My GP was extremely helpful and made a referral to CAMHS, however, there is a

seven-month waiting list.”

 

“My daughter has been referred to CAMHS for PTSD and low mood, however,

there is an eight month wait for this.”

 

“The counsellor at my daughter’s school is very good and offered to do some

sessions for me too. I went back multiple times and found it helpful.”

 

“The caller said she was told how she was feeling was normal and that they would

call her in three weeks. This wasn’t helpful as at the time she needed to speak to

somebody.”

 

“I feel as though the email received in October could have been sent earlier to

those who had been affected by the attack. I feel as though I have come a long

way since May. I’m less jumpy, having less nightmares and emailing my story was

nice to get it off my chest.”

 

“The attack has affected my mental health to the extent that I have been unable to

start my university course as planned. My mental health deteriorated, I had to

seek private psychotherapy after being diagnosed with PTSD and anxiety.”

 

“I have been in touch with the Survivors’ Network as well as the Manchester

Resilience Hub and they all provided great support. The Foundation for Peace

have written to the children’s school with tips on how to support them.”

 

“My place of work paid for private counselling sessions; I was a mess and did not

stop crying for the first three sessions. I have not been in work since the attack. I

spend most of my time talking to a war veteran who gives me support.”

4.39. The strategy was to communicate a ‘normalisation’ and support message not only

in Greater Manchester but via NHS national networks. The advice given was that

directing people into treatment at an early stage was potentially harmful and was

an inappropriate response to normal responses which people experience after

such an incident. If, after four weeks, people were experiencing difficulty e.g.

mood shifts, trouble sleeping, experiencing panic, then they should be pointed to

further mental health support. This advice relating to psychological reactions to

traumatic experiences was widely circulated within hours of the incident,

describing what were normal reactions, when to seek help, and from where to get

help. Efforts were made to circulate these messages through a range of media

platforms including digital and broadcast

 

Dr Mike Scott

NOTE: Victim Support provided the front door in the 1st 4 weeks after the bombing

Shifting The Focus To The Client Being Well

Conferences, government agencies such as IAPT and recent research papers, gloss over the proportion of clients who are well at the end of CBT (remission), preferring instead to talk of the number of people who have responded (response) to an intervention (proportion of people whose score reduced by greater than x%). Springer et al (2018) call for a shift in focus to the real world outcome of remission ‘remission should be the ultimate goal of treatment’. Chasteningly they point out  that the remission rate for CBT across the anxiety  disorders is just 50%.

Interestingly the results of Springer et al’s meta-analysis showed that the remission results were poorer when there was no blind evaluator. This may be important in evaluating IAPT’s performance because they have had no independent evaluator! Further the results in the Springer analysis were poorer still when there was comorbid conditions such as depression and/or subtance use disorder, suggesting that all a client’s disorders need tackling not just the primary anxiety disorder. GAD and PTSD did better than OCD and SAD with panic disorder in between.

Clients want to be well again not just reduce their score on a psychometric test that some clinician deems acceptable for their own reasons. Losing their diagnostic status should be a necessary condition  for assessing outcome, albeit that arguably it also ought to be complimented with reduction below a certain cut-off on a psychometric test.

 

Springer, K.S., Levy, H.C and Tolin, D.F (2018) Remission in CBT for adult anxiety disorders. A meta-analysis. Clinical Psychology Review, published online ahead of print

Please cite this article as: Springer, K.S., Clinical Psychology Review (2018), https://doi.org/10.1016/j.cpr.2018.03.002

Dr Mike Scott

IAPT Problem Descriptors Lead To Treatment Chaos

IAPT base treatment on problem descriptors not standardised diagnosis, resulting in a gross failure to identify appropriate treatment targets. A recent study by Thomlison et al (2017) indicated 4 out of 5 PTSD cases were missed.    There is no evidence that identification of other disorders is any more reliable Scott (2018) see earlier post (link below)

In the Thomlinson et al study (2017) three quarters of IAPT clients were in low intensity groups, conducted without reference to any explicit evidence based protocol. This looks like playing a numbers game with groups.

Thomlinson et al (2017) Comorbidity between PTSD and anxiety and depression: Implications for IAPT Services. Archives of Depression and Anxiety

Scott, M.J (2018) IAPT – The Need for Radical Reform Journal of Health Psychology https://connection.sagepub.com/blog/psychology/2018/02/07/on-sage-insight-improving-access-to-psychological-therapies-iapt-the-need-for-radical-reform/.

 

 

 

Dr Mike Scott

IAPT at Sea On Risk Assessment

A study just published by Na et al (2018)  in the Journal of Affective Disorders*  suggests that item 9 of the PHQ-9 is an insufficient assessment tool for suicide risk and suicide ideation, creating large numbers of false positives. Yet within IAPT, GP’s may be informed that either there are no risk issues on the basis of a ‘not at all’ response to  item 9, ‘thoughts that you would be better off dead or of hurting yourself’ or that there are risk issues on the basis that they have been bothered by these thoughts for at least several days in the last 2 weeks. The message is usually communicated to the GP following a telephone assessment conducted by the most junior members of staff a Psychological Wellbeing Practitioner. The GP then feels obliged to call the patient in for an assessment which turns out to be invariably pointless, not good for the patient or for the GP who may be seeing 40 patients that day!

A (2012) paper on IAPT by Vail et al ** stated ‘that IAPT clinicians did not have set procedures or questions for assessing mental health risk, and were  flexible in the approaches they adopted. They often relied upon their own clinical judgement and experience about how to approach the topic of mental health risk’. This chimes with what I found in an analysis of 90 cases going through IAPT, Scott (2018) in only three cases was there mention of risk in the documentation. Inspection of item 9 on the PHQ-9 shows that it confounds passive suicidal ideation with active planning making it unclear what the frequency response refers to, creating many false positives.

More direct questionning based on the C-SSRS * is probably more appropriate:

Have you started to work out or worked out details of how to kill yourself? Do you intend to carry out this plan ?

Have you made a suicide attempt- purposely tried to harm yourself with at least some intention to end your life?

Have you  taken any steps to prepare to kill yourself or actually started to do something to end your life or were stopped before you actually did anything?

A none response to either of the 3 questions would indicate no suicide risk.

* Na, P.J et al (2018) The PHQ-9 item 9 based screening f or suicide risk: a validation study of the Patient Health Questionnaire (PHQ) – 9 item 9 with the Columbia Suicide Severity Rating Scale (C-SSRS) Journal of Affective Disorders, 232, 34-40.

** Vail, L (2012) Investigating mental health risk assessment in primary care and the potential role of a structured decision support tool, GRIST. Mental Health in Family Medicine, 9, 57-67

 

Dr Mike Scott

PTSD and Winnie-the-Pooh

Winnie-the-Pooh’s 100 Acre Wood has taken on a whole new meaning, after watching on DVD ‘Goodbye Christopher Robin’. The ‘Wood’ is arguably A.A Milne’s construction of a new personal world for his son (Christopher Robin), an alternative to the war zone map he appears to have operated on  since  his involvement in the Battle of the Somme in 2016, his illustrator had been involved in the Battle of Paschendale in 2017. The DVD  sees the playwright A.A Milne returning to London after his war experiences, needing to retreat to the country, startled and debilitated by unexpected noises, unhappy to make people just laugh dismayed at his son going off to another war.

 

It seems that the quest post-trauma is to seek a better map, oftentimes returning to the pre-trauma map but perhaps sometimes creating an altogether better map. Perhaps some clients are a little like Eye-ore because of their experiences!

 

Dr Mike Scott

 

Is Aggressive Management Endemic in the Mental Health Field?

This week the demise of the construction Company, Carillion was laid at the door of aggressive management – hiding the true nature of performance. Isn’t this what IAPT have done with claims of a 50% recovery rate, when the actual recovery rate was 10% [ Jounal of Health Psychology, ‘IAPT- The Need for Radical Reform ‘http://journals.sagepub.com/doi/pdf/10.1177/1359105318755264  http://journals.sagepub.com/doi/full/10.1177/1359105318755264.  With two thirds of IAPT low intensity workers suffering burnout, as well as half of those in high intensity it looks suspicious.

 

 

My experience yesterday  giving a talk ‘From Disaster to Functioning’ [ slides here https://www.dropbox.com/s/0jgvhhz0bva81s2/From%20Disaster%20to%20Functioning.pptx?dl=0 and http://www.cbtwatch.com/from-disaster-to-functioning/ ] at the Health and Wellbieng Conference held at the NEC, Birmingham suggests that misrepresentation is not confined to IAPT, I heard of mental health wares such as suicide prevention packages and the Critical incident Stress Debriefing  variant TRIM, being promoted despite a dirth of evidence supporting them. I began writing this blog on the train yesterday coming home from the Conference, as I was getting off the attendant announced “if you see anything suspicious see it, report it sort it”,  it  may be an important dictum for the whole mental health  field.

 

Dr Mike Scott

What If Information Processing Models of PTSD are Wrong?

Consider that only a small minority of those experiencing an extreme trauma experience PTSD, consider also that most people experiencing such an event try not to think/talk about it, is it really plausible that PTSD arises from arrested information processing? If not why are we subjecting clients and therapists to a painful procedure, trauma focussed CBT/EMDR,  that they are likely to default from?

?

?

It is true that with trauma focussed CBT or EMDR about 50% of those undergoing these treatments in randomised controlled trials fully recover from PTSD, nevertheless compliance in routine practise appears much less . But it is possible that to the extent that these treatments do work they do so for reasons other than achieving ‘full processing of the traumatic memory’. More plausibly as a side effect of these interventions they learn experientially that the ‘war zone’ map of their personal world that they have employed since the trauma, leads nowhere and they revert to a pre-trauma map. Oftentimes the prime concern of a victim is not what did happen but what could/should have happened i.e it is not the trauma per se.

Dr Mike Scott