The Entire IAPT Process Is Based on Deception

Is it possible to stop fake psychological therapy by telling the truth? The client is at a railway station to board a train to where he/she knows not, but seeking a better life. They may have arrived at the station under their own steam and/or at the promptings of family/friends/GP. But the ‘trip advisors’  have rarely visited/evaluated the destinations. In social psychology terms the advisors have not engaged in effortful central processing of outcome data. Bypassing the latter with a heuristic (peripheral processing) that the IAPT service’ must be good because it is NHS/Government funded and in any case the mental health burden will be shared out’.

 

The client believes that they will encounter mental health professionals who can reliably diagnose and treat whatever disorder they have. But nobody told them the service does not make diagnoses [IAPT Manual (2019). At the 30 minute telephone assessment the Psychological Wellbeing Practitioner does not tell them that: a) they are not trained to diagnose b) nor trained to provide psychological therapy and c) in the first instance they will likely undergo low intensity CBT of undetermined potency in treating depression and the anxiety disorders. The deception makes for easy boarding of the IAPT train. The PWPs cram the clients onto the train by using low intensity interventions but unsurprisingly 69% of PWPs suffer burnout, whilst the rate of burnout amongst high intensity therapists is 50% [ Westwood et al (2018)] . To help mitigate their stressors the PWPs have regular supervision, but this to is a deception, as they often have less than 3 minutes to discuss a case. Over a third (38%) [Psychological Therapies Annual Report (2020-2021)] of clients get off the train before their 2nd treatment session, but that is not at places where they want to be. Nobody told them at the start of this level of dissatisfaction. Likewise nobody told them only the tip of the iceberg reach a destination where they have lost their diagnostic status Scott (2018), 9 out of 10 remain at square one. But IAPT keeps up the pretence advising the ‘trip advisors’ and Clinical Commissioning Groups of a 50% recovery rate. A million a year now enter the IAPT gates. It is difficult to escape the parallel as to how people were conned into Auschwitz.

 

Dr Mike Scott

Antidepressants and CBT in The Real World

A 24%  response rate combining the two, and manual driven psychotherapy conferred no added benefit Bartova et al (2021). In the podcast from Mad In America these findings are set against a 31% placebo response rate. Further no evidence that the interventions altered the course of a disorder, which is the prime objective of treatments for physical disorders. Rather the focus was on symptomatic relief. Articles covered in podcast include:

 

Pies and Dawson (2022) have today taken up the cudgel to attack the findings of Moncrieff et al (2002) that were the springboard for the podcast. But they are disingenuous in claiming that no one of academic credibility has ever suggested that low serotonin causes depression. For decades, at least in the UK this has been the dominant message given to patients, with the implication that they need antidepressants to restore the chemical imbalance. Pies and Dawson (2022) have recourse to a biopsychosocial model which posits interactions of thoughts, feelings, social factors and biology, in which will be found some biological factor that is of key importance in the development of depression and through which antidepressants will be found to work. But given the track record to date this seems unlikely and provides little basis for current pharmacological practice with the exception of the use of lithium. 

In the Bartova et al (2021) study the therapists claimed that they were adhering to a manual driven psychotherapy protocol, but no fidelity checks were made. A  similar scenario to the claim made by IAPT in the UK that it delivers CBT, but without any independent corroboration. It is I believe the case that CBT can make a real world difference for depression and the anxiety disorders if appropriately delivered.

 

Dr Mike Scott

What Is The Simplest Explanation of How Clients Fare In The Improving Access to Psychological Therapies Service?

 

The philosophical principle of Occam’s Razor suggests that the simplest explanations are usually the correct one. Most will present to IAPT at their worst and there will be some improvement with the passage of time and attention. But clients could just as easily have benefitted from attending the Citizens Advice Bureaux,  i.e there is no added benefit from IAPT. Last year over a third (38%) of those who accessed the IAPT service attended one or less treatment session, and it is unlikely that they would benefit from such a sub-therapeutic dose of therapy.  The suspicion is therefore that IAPT doesn’t work. If one tries to explain the therapeutic gains of defaulters (defined by IAPT as attending less than 2 treatment sessions) from the Service, complexity enters. The confusion is not lessened when one tries to explain how it is that completer’s attending on average of 7.5 sessions, apparently make gains comparable to those in randomised controlled trials, with just half the number of sessions! IAPT’s claims beggar belief.

CBT is allegedly ubiquitous in the Improving Access to Psychological Therapies (IAPT) service. Overall a 50% recovery rate is claimed. How then is it effective with one out of two completers of treatment but also ineffective with one out of two? We enter the black hole again.

It is axiomatic amongst CBT adherents that negative cognitions and avoidance behaviours perpetuate negative emotional states. It is further assumed that targeting these maintaining agents will resolve the negative emotional state. But this latter scenario will only unfold if the negative cognitions and avoidance behaviours are pivotal in the onset of the negative emotional state. If a person is suffering from, say chronic fatigue syndrome the salience of negative cognitions and avoidance behaviours may be questionable. The biopsychosocial model of CFS advanced by Deary et al 2007 is of such complexity, that no aetiological agent e.g child neglect, could be ruled out. Applying Occam’s Razor the likelihood is that a primary physical basis for CFS will be found or that it actually covers a range of disorders each with a different biological base. 

In the case of depression negative life events and neuroticism are strong predictors. But neuroticism could be the driver for negative cognitions and avoidance behaviours. However neuroticism itself maybe a product of a particular style of engaging in mental time travel, in which negative events are given a particular salience and homage is paid to them with avoidance behaviour. It is scarcely credible that 7-8 sessions of CBT therapy will nullify the effects of neuroticism/mental time travel for a period that the client would see as clinically meaningful e.g 8 weeks.

Dr Mike Scott

When is evidence based practice not evidence based practice?

When it is not using the latest evidence. An article in the Cognitive Behaviour Therapist, much lauded by the Editor of the Journal, highlights this. There was no review of the latest group CBT for PTSD outcome studies see Scott (2022) Personalising Trauma Treatment: Reframing and Reimagining London: Routledge. Instead the authors relied upon the conflicted, dated, recommendations of guideline producers. Guidelines are  produced by Committee decisions with all the vagaries that entails, they are not the results of a systematic analysis of data. My book includes  a review of group CBT outcome studies for PTSD (reproduced at the end of this blog), indicating the inferiority of a group approach.

 

In this study of group CBT for PTSD, the results of 3, 8 session (2hrs per session) group programmes are summarised by the treating IAPT workers. But no standardised diagnostic interview was used at any point, so it is unknown what proportion of people lost their diagnostic status for how long. Nor whether they were truly suffering from PTSD in the first place, making independent replication impossible. It is claimed that the treatment was given to those who ‘preferred’ group therapy but this is disingenuous. In practice people are offered more immediate treatment with a group or a long wait for individual therapy, whilst they may opt for the former, it is not a preference. 

8 is The New Magic Number

The tail is wagging the dog, in that the authors have fitted in with the growing fetish for 8 sessions. Those who complete IAPT treatment typically have 7.5 sessions. Further NICE recommend, 8 group CBT therapy sessions for depression as the first line treatment for depression. But there is no empirical evidence that 8 sessions of anything makes a real-world difference. It is simply what the powers that be have decided to ration out. There is no indication of the mechanism of action of 8 sessions. If it is not possible to specify how a claimed result is achieved then the latter is suspect. BABCP has just celebrated its 50th birthday by a return to magic.

Group Treatments

Groups are an attractive option for service providers, offering the prospect of reduced waiting lists and greater access to therapy. But comparisons of group interventions show them to be inferior to individual therapy post-trauma and to offer no added benefit to treatment as usual. Kearney et al. (2021) compared the effectiveness of group cognitive processing therapy (CPT) for the treatment of PTSD with group loving-kindness meditation (LKM) which involved the silent repetition of phrases intended to elicit feelings of kindness for oneself and others. The proportion of veterans who lost their diagnostic status i.e. who no longer suffered from PTSD did not differ at the end of treatment (CPT – 29%, LKM – 27.5%). Each intervention consisted of 12 weekly 90-minute group sessions but the mean number sessions completed was only six in CPT and seven in LKM. Resick et al. (2017) found that in a population of veterans group CPT was inferior to individual CPT. Preparatory group treatment for CPT or prolonged exposure does not enhance outcome. Dedert et al. (2020) examined whether a preparatory group with a focus on psychoeducation, coping skills, sleep hygiene and an introduction to PTSD treatment options added benefit to the trauma-focussed interventions, it did not. Further, those who went through a preparatory group did less well than those who did not in whatever trauma-focussed CBT they went onto in terms of PTSD symptom reduction. There is no evidence that initial Stabilisation Groups contribute to treatment effectiveness. However, the aforementioned studies were all on veterans, so care has to be taken in generalising from the results. But a study by Mahoney et al. (2020) of women prisoners who reported a history of interpersonal violence and trauma found that a ten-session group psychoeducational programme, Survive and Thrive, conferred no benefit over treatment as usual.

There appears to be no benefit to a phase-based approach, in which the first phase has as its goal safety and stabilisation, despite the inherent attractiveness of this option.

Scott, Michael J. Personalising Trauma Treatment (p. 293). Taylor and Francis. Kindle Edition.

 

 

CBT Outcome Studies – An Example of The Problems of Generalisation

The problems of generalising from CBT randomised controlled trials can be illustrated by examining the following just published study from Clark et al (2022):

 

  1. All patients were referred by an Improving Access to Psychological Therapies (IAPT) Service if they were thought to be suffering from social anxiety disorder(SAD). But following detailed diagnostic assessment only one half were found to be suffering from the disorder. Thus it seems likely that IAPT staff, left to their own devices, would have provided inappropriate treatment for one in two patients.
  2. IAPT staff do not make assessments using standardised diagnostic interviews, so that there can  be no certainty that the results of this, or any other credible randomised controlled trial, would translate into routine practice.
  3. The three treatment  clinicians involved in the trial involved were experienced, well known clinical psychologists, unlike the therapists in routine practice. It is unlikely the latter would achieve the same outcome as the former.
  4. In the study internet delivered CBT and standard CBT were the active comparisons and the results set against a waiting list control condition. But patients on a waiting list do not expect to get better and this comparotor has therefore been termed a nocebo. Given such able clinicians, it is possible that, if they had provided an alternative treatment with a credible rationale e.g ‘managing shyness/better mixing’ with equal attention the results would not have been appreciably different. The chances of this are increased by Clark et al (2022) finding that many of the standard components of the original CBT, such as accompanying the patient to social experiments were found to be redundant.   
  5. The study authors were evaluating, the computerised CBT program that they had developed. But no mention that the study  requires independent replication because of the possibility of allegiance bias. Interestingly the authors report no conflict of interest. 
  6. The study required patients to have internet access and almost two thirds had higher education. The results may not be applicable in forgotten towns.
  7. Patients were required to have SAD as their main problem, but patients typically see themselves as having a range of difficulties and want treatment for all. In this study 30% were found to be suffering from depression. But strangely, overall the pre-treatment mean on the PHQ9 was below the cut off of 10 usually used to denote a case of depression. Further this score is much lower than the initial mean of PHQ9 scores in the IAPT population.  This creates doubts about the level of functional impairment in this population. 
  8. On the surface the study results are remarkable with 70%+ recovering from SAD and avoidant personality disorder. But the primary outcome measure was a composite of loss of diagnostic status and achieving below cut-off scores on several SAD self-report measures. There could be no certainty that the components of the composite were equally important to each patient, nor that the frequencies of say loss of diagnostic status and below cut off scores matched. The hazards of using composites has been highlighted by McCoy (2018).
  9. Patients see recovery as being free of a disorder for a meaningful length of time. Given that persistent SAD is defined in the DSM as having the disorder for at least 6months. It therefore seems reasonable to suggest that a primary outcome measure should have been being free of SAD for at least 6 months. This would have been a real world change.

This study is a salutary tale about the marketing of CBT – the takeaway message in the title is that the cost of one intervention(internet CBT) is half the cost of standard CBT. This is not to say that CBT is not of limited utility with depression and the anxiety disorders (including OCD and PTSD) but we need to assess what is of real world importance to the patient.

 

Dr Mike Scott

1 in 7 Taking Antidepressants Despite Increased Access To Psychological Therapy

Maybe the antidepressants and/or psychological therapy  are  not making a real-world difference? Is it more likely than not, that one or other of these treatments works? I do not think that I could prove either to a Court’s satisfaction. Attempts to deliver them are taking a terrible toll, with a focus on Key Performance Indicators (KPI’s) rather than the client’s story. Taking these treatments in turn:

 

Antidepressants. There has been a doubling of the prescription of antidepressants  from 2006 to 2016, followed by increases in the prescription of antidepressants for 6 years [BBC News, July 9th 2022]. The BBC News  confidently asserted that a major study proved antidepressants work, citing a link to a study published by Cipriani et al in (2018) in the Lancet. But it was only in a footnote that the BBC reporter acknowledged that the meta analysis covered, predominantly studies that looked at the effects of taking the medication for 8 weeks. There is no evidence that antidepressants alter the course of a persons mental health. Journalists like to give a human angle, and so the BBC presented an individual who had benefitted from antidepressants. But equally, I could have furnished an example of a guy I saw recently with depression as a consequence of being unable to do his manual job, because of a physical injury, who has been prescribed various SSRI’s and he has lost his libido, with a deleterious effect on his long term relationship and no loss of diagnostic status. One cannot rely on anecdotes to bolster the claim for either antidepressants or psychological therapy.

Psychological Therapy.  Billions of £’s have been spent on the Improving Access to Psychological Therapies (IAPT) Programme over the last decade.  But there has been no publicly funded independent audit of IAPT. Why? Vested interests and a deep desire to believe that antidepressants and IAPT ‘must’ be making a difference. I examined the effectiveness of CBT in routine practice for 90 IAPT clients in the course of my work as an Expert Witness to the Court Scott (2018) and found that only the tip of the iceberg recovered (i.e lost their diagnostic status) using a ‘gold standard’ semi-structured interview. Further it mattered not whether they were treated before or after their personal injury. It has been said that human beings can only take so much reality, if so, following the scientific edict to ‘follow the data’ is likely to prove more aspirational than actual.  

I cannot see any Expert Witness clearing an, on the balance of probability threshold, with regard to either of these interventions, as delivered in routine practice, in a British Court. 

 

Dr Mike Scott

 

 

NICE Rubber Stamps Business as Usual

despite the fact that the main provider of psychological services, the Improving Access to Psychological Therapies (IAPT) Service is ‘An Abject Failure’ https://www.madinamerica.com/2022/06/uk-iapt-abject-failure/. It is all about cost, with no regard for evidence. It is recommended by the National Institute for Health and Care Excellence (June 29th) that clients are offered 11 possible interventions for depression, presenting the least costly first, guided self-help, group cognitive behavioural therapy (8 sessions) progressing up to the 11th option, short term psychodynamic psychotherapy. With Psychological Wellbeing Practitioners (PWPs) providing the assessment and the least costly interventions. But PWPs are not trained therapists and the IAPT Manual states that its’ employees do not make diagnoses and they are not trained to diagnose. Yet bizarrely NICE states that assessors must be competent to make a reliable assessment of depression! A pig’s ear of monumental proportions. 

There is no empirical evidence that 8 sessions of group CBT delivered by PWPs makes a real world difference to client’s lives as assessed by a blind assessor. Nor that the recommended 8 sessions of individual CBT for depression, presumably delivered by a high intensity therapists, constitutes a therapeutic dose of treatment. 

The revision of the Draft Nice Guidance on Depression https://www.nice.org.uk/guidance/ng222 now recommends a stepped care approach to depression and sees Psychological Wellbeing Practitioners as contributing to treatment. This has brought a ‘hurrah’ from BABCP (British Association for Behavioural and Cognitive Psychotherapy),  as it is exactly what they lobbied for https://babcp.com/About/News-Press/Revised-NICE-Guideline-on-Depression-in-Adults post the Draft guidelines. Dr Andrew Beck the BABCP President proclaims in the press release ‘the guidedInes highlight the amazing value of PWPs’.  In addition antidepressants and CBT in combination are seen as the treatment choice for severe depression.

But these recommendations and changes are eminence-based not evidence-based. A paper published in the Journal of Psychiatric Research last year by Bartova et al (2021) https://doi.org/10.1016/j.jpsychires.2021.06.028 showed a 25% response rate for those who had antidepressants and manual-driven psychotherapy (mostly CBT), no better than antidepressants alone. This compares with a 31% response rate in those given a placebo Rutherford and Roose (2013) https://doi.org/10.1176%2Fappi.ajp.2012.12040474

Before BABCP issued the press release, I raised the following issues with its’ author Professor Reynolds:

  1. I can find no randomised control trials of low intensity interventions that are methodologically robust enough to lead to the conclusion that such interventions should be the initial treatment of choice for less severe depression.
  1. I can find no evidence that as a result of stepped care, the trajectory of clients with depression Is meaningfully better than if they were not treated in a stepped care model.
  2. There was criticism of the initial draft for the ‘marginalising and undervaluing of PWPS’. However, it appears that under pressure from BABCP, PWPS are now to be lauded. But there is an absence of evidence of what PWP treatment works for whom and in what circumstances. As such their interventions are not evidence- based. Further they are not psychological therapists.
  1. NICE have apparently indicated that the IAPT database may be used to inform the next set of guidelines. But this database tells us nothing of the course of any client’s disorder as the service does not make diagnoses or engage in long-term follow up.

I asked that my dissent from BABCPs press release be publicly noted, and was told simply that it would be passed to the BABCP Board. At the same time the comments of IAPTs lead, Professor Clark. on the importance of including relapse prevention in treatments, would be included in the press release and it was.  An in-group clearly operates. I am reminded that when I submitted an article to the BABCP comic, CBT Today on IAPT, the article was rejected not by the editor but by the past (Prof Salkovskis) and current (Dr Andrew Beck) Presidents of BABCP. The matter was never addressed by the Board despite an assurance from Dr Beck. If ever there was a clique. Unholy alliances rule.

Dr Mike Scott

 

The UK’s IAPT Service Is An Abject Failure

 

from ‘Mad In America’ https://www.madinamerica.com/2022/06/uk-iapt-abject-failure/

 

Rescued man in boat looking on shipwreck

Dr Michael J Scott Ph.D

In 2012, an editorial in the prestigious journal Nature claimed that the UK’s IAPT Service is “world-beating”—meaning that the service is the world’s best for treating mental health concerns. Now that 10 years have passed, it’s clear that this was not true. Despite the hype, the IAPT is hardly “world-beating.” In fact, it is a doubtful model for other countries to follow.

The IAPT (“Improving Access to Psychological Therapies”) was created in 2008 and fully funded by the UK government (though restricted to provision only in England). The program claims to provide evidence-based psychological treatment, most commonly in the form of cognitive behavioural therapy. It was initially focused on patients with depression and anxiety disorder diagnoses, but its scope has been gradually expanded to include the psychological treatment of long-term physical conditions such as chronic fatigue syndrome.

Patients either self-refer (at no cost) or are referred to the IAPT by their primary care physician/general practitioner. Clients are initially assessed during a 30-minute telephone conversation by a Psychological Wellbeing Practitioner (PWP) who is not an accredited therapist and is not trained to diagnose. IAPT clients initially receive low-intensity CBT (six hours or less of therapy contact) delivered by a PWP. If they are deemed not to have responded to this, on the basis of a psychometric test, they can be “stepped up” to high-intensity CBT delivered by an accredited psychological therapist.

How Well Is the IAPT Doing?

Proponents of the IAPT cite its outcomes for the clients who complete their treatment sessions—but over half of IAPT clients don’t even attend two sessions. The response of the IAPT to this massive disengagement with the service—clients “voting with their feet,” as it were—is currently to offer training to its staff to “streamline” matters by encouraging them to use a computer algorithm to decide which clients go where. This training, which was held on June 22, 2022, involves expert advice from the CEO of Limbic, an artificial intelligence Company. Thus, not only are IAPT staff to be distracted by clients having to complete psychometric tests at each encounter, but now additionally by the administration of the computer algorithm.

Yet Limbic claims it is “an AI assistant for clinical assessments in IAPT—improving access, reducing costs and freeing up staff time.” Where is the independent evidence for this? What clients really want is to be listened to, but there is little chance of this any time soon. Conquering disengagement in this manner is a forlorn hope. 

IAPT’s 2019 manual states that IAPT staff do not make a diagnosis. However, the treatment recommendations of NICE (the UK’s National Institute for Health and Clinical Excellence) are explicitly tied to a taxonomy of specific treatments for identified disorders (largely, diagnosis-specific variations on CBT). IAPT legitimises itself by a claim to be NICE compliant, but how could they be if they don’t make diagnoses? How can they follow NICE’s specific treatment guidelines without first assessing which condition they are treating?

Whilst the IAPT’s claim to be NICE-compliant might be music to the ears of NHS England and clinical commissioning groups, it is simply not true. No independent fidelity checks have ever have been made on IAPT’s ministrations. IAPT allegedly provides specific CBT protocols for different disorders, but it has provided no evidence that it does this.

In my examination of the physician’s records of 90 IAPT clients, I found no evidence of compliance with CBT protocols.IAPT operates simply as a business with superb marketing.

In no independent audit of IAPT, have clients been asked “are you back to your usual self since this treatment?” This is a goal that is meaningful to the client—with the possible supplementary question, “for how long have you been back to your usual self?” In papers published by IAPT staff, no such real-world outcome measures have ever been used. Instead, reliance has been placed on changes in psychometric test scores. Yet without a control group, it’s impossible to know whether these changes would have occurred with passage of time anyway. After all, people present to psychological treatment at their worst, and at any other time, they are likely to score better. In statistics, this principle is known as regression to the mean, and it is vital to account for this effect.

Further, the client knows his/her therapist sees their completed questionnaire, pushing them to respond more positively. A client may also not want to endorse negative responses on the questionnaire because it would mean acknowledging that they have wasted their time in therapy. These are known issues with self-report measures that are commonly cited as important limitations in research studies.

Finally, the questionnaire results also give no indication of whether any improvement has lasted for a period that the client would regard as meaningful, such as eight weeks or (hopefully) more.

In an era of personalised medicine, it is essential that the voice of the client is heard. It is an almost ubiquitous failure of studies to employ a primary outcome measure that a client can identify with—known as patient-centred outcomes. Perhaps the nearest proxy is loss of diagnostic status (full recovery) determined by an independent assessor. The burden of proof rests on providers of services to demonstrate that their treatments are making an important difference to a client’s life in a way that is clearly recognisable to the client. IAPT has not cleared this evidential bar.

Use of an algorithm is not incompatible with a clinician operating on a knowledge base of what works for whom. But it has to be first demonstrated that the former constitutes added value over the latter. The burden of proof is on AI advocates to demonstrate its relevance in a particular context. This cannot be done by a company with a vested interest in AI.

It is perfectly possible that using two systems, an algorithm and clinical judgement, might create confusion. Should an IAPT client not fare well (for example, if a client dies by suicide) when treated under such a dual system, could IAPT convince a court, on the balance of probability (the UK benchmark in personal injury cases), that its approach was evidence-based? After all, an AI approach is not something that NICE has recommended—so it flies in the face of the guidelines. Traditionally, courts are swayed by eminence-based evidence (such as the word of authority figures like psychiatrists), but they have become more aware (at least in the UK) of the perils of unbridled clinical judgement.

Inadequacies of IAPT’s Chosen Metric

IAPT’s chosen metric is a change in score on two psychometric tests. Clients are deemed to have responded if on the PHQ-9 (a measure of the severity of depression) their test score has gone from above 10 to below 10 with treatment, with a difference of at least 6 points, and if on the GAD 7 (a measure of the severity of generalised anxiety disorder) their score has gone from above 8 to below 8 with treatment, with a difference of at least 4 points. This approach has numerous deficiencies:

  • It is not known whether the completer of these two measures was actually suffering from depression or generalised anxiety disorder, because IAPT clinicians do not make diagnoses. Further, it is not known whether either of these “conditions” was the disorder that was causing most impairment in functioning.
  • When test results are observable by the treating clinician, clients may wish to be polite and relay a lower score, particularly as they do not want to feel that they have wasted their time in therapy.
  • No attention control comparator: Changes in test scores are meaningless unless there is a comparator group who have received the same attention and a credible rationale. It’s unclear whether the therapy resulted in the improvement, or if the client would have improved with a “placebo” therapy (simply receiving professional “attention” without CBT techniques).
  • Regression to the mean: Clients typically present at their worst, so with the mere passage of time they will score more modestly.
  • The vagaries of a minimally important difference (MID) in a score: MIDS are established by statistical comparisons between an “ill” and “well” group, but they do not necessarily indicate clinically important difference. They also fail to address the client’s perception and there is no personalisation of treatment outcome. Clients are given no voice.

Haemorrhaging

Last year about a third of referrals (30.1%) to the IAPT service did not access it. Of those who accessed the service over a third (38%) had just one treatment session. Thus, by the start of the IAPT race over half of people (57%) have not engaged in treatment (as defined by IAPT’s metric of attending two or more sessions). If these results applied to a physiotherapy service it would raise serious doubts about the suitability of the service! Why then does the UK National Audit Office studiously avoid scrutiny of IAPT, which costs the taxpayer over £1 billion a year?

Sub-Therapeutic Dose and Treatment Outcomes

Of those who engaged in IAPT, the average number of sessions was 7.5, which is well below the 12 to 20 sessions that NICE recommends for depression and anxiety disorders (IAPT’s primary targets). Are we to believe that IAPT’s clinicians are so skilled that they can achieve recovery with only half the dosage of therapy as that delivered by therapists in the randomised controlled trials of CBT for depression and the anxiety disorders?

The benchmark set by trials of therapy as a treatment for these conditions is that at least 50% must “recover” (no longer meet criteria for a diagnosis). But there is no evidence that IAPT has achieved this. My own research suggests that only the tip of the iceberg recover.

In my capacity as an Expert Witness to the Court, I examined 90 IAPT clients who had been through the service either before or after the personal injury. Only 9.2% of subjects lost their and diagnostic status, as assessed using the “gold standard” SCID interview. It mattered not whether subjects were assessed before or after their personal injury. (These findings are in need of replication by clinicians independent of IAPT with a non-litigant population.)

Diagnostic Creep

IAPT appears not to so much follow the data, but to follow funding opportunities. It has branched out into territory were angels fear to tread: Medically Unexplained Symptoms (MUS). MUS is an umbrella term embracing conditions as diverse as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome. IAPT’s contention is that exaggerated negative beliefs about symptoms, and maladaptive behaviours (e.g., avoidance), play a pivotal role in the maintenance of symptoms in these conditions. The therapeutic task, as they see it, is to then to modify these cognitions and behaviours.

What happens if a client protests that they have valid medical symptoms? Well, IAPT clinicians are taught not to openly disagree and not to say ‘it is all in your mind’. But to nevertheless continue to focuss on the ‘exaggerations in beliefs and avoidance behaviours’, so much for honesty.

Along with Keith Geraghty from the University of Manchester, I have published a critique of this sojourn. We identified a series of seven core problems and failings of the IAPT, including an unproven treatment rationale, a weak and contested evidence-base, biases in treatment promotion, exaggeration of recovery claims, under-reporting of drop-out rates, and a significant risk of misdiagnosis and inappropriate treatment. We concluded that psychotherapy should not become the default option when patients have “medically unexplained symptoms.”

The term “medically unexplained symptoms” should be written in lowercase to avoid conveying the impression that a meaningful homogenous entity is being described. The term should not enter the taxonomy of disorders. Importantly, even the DSM-5 has shunned recourse to the term. But unfortunately, IAPT only pays lip service to the standard diagnostic criteria.

Big Pharma and IAPT

Whilst some large pharmaceutical companies have greatly served the public good with regard to COVID, their performance with regard to psychotropic drugs is much less impressive. Researchers like Read and Moncrieff pin their hopes on the efficacy of CBT demonstrated in randomised controlled trials, but make no mention that CBT as delivered in routine practice bears little relationship to the protocols utilised in RCTs. Just as the claims of pharmaceutical companies require critical appraisal so too does the UK IAPT service.

 In an article in the British Journal of Clinical Psychology, I explained what the IAPT needs to do to get back on track. I noted that in their published papers, IAPT staff do not declare their allegiances and indeed state that they have no conflict of interest! This dishonesty needs to change. I suggested that there is a need for IAPT to prove their case using the standards of proof that are required in other areas of medicine.  To this effect, they cannot simply claim that they deliver evidence-based treatment—there has to be documented evidence for it that would be persuasive to an independent observer.  The IAPT service has to demonstrate that it provides an added value over someone attending an advice centre or counselling service. Yet the IAPT has yet to demonstrate that it makes an important enough difference to clients’ lives that they would recognise it.

This catalogue of omissions may create a sense of déjà vu for those who have followed the machinations of Big Pharma with regards to mental health. Unfortunately, there has only been a deafening silence from the IAPT regarding my critique.

 

 

 

The IAPT Double Myth of Economic and Clinical Utility

 

The impetus for the Improving Access to Psychological Therapies (IAPT) service was derived from a) economic considerations and b) an assertion that the positive results of randomised controlled trials of, primarily CBT, for depression and the anxiety disorders would be realised in routine practise.

 

 

A Money-Saver?

In 2006 the Centre for Economic Performance stated that “the total loss of output due to depression and chronic anxiety is some £12 billion a year-1% of our total national income ”. The contention was that investment in psychological therapy would pay for itself by a reduction in such costs. But currently IAPT costs over £1 billion a year, where is the evidence of a substantial reduction in the loss of output? Where is the evidence that IAPT constitutes a no-cost talk therapy?

 

Poor Performance at the Coal-Face

In the randomised controlled trials on average 50% of clients lost their diagnostic status as assessed by independent blind assessors. But no such unbiased assessors have ever gauged the impact of IAPT’s ministrations. IAPT has always marked its own homework. Rather than the claimed recovery rate of 50%, the best available evidence suggests that only the tip of the iceberg recover, Scott (2018).

Each myth means that the other is not carefully examined and IAPT advocates can deftly switch the focus from one to the other under critical scrutiny – a politician’s dream.

 

Psychological Therapy – a history of exaggerated claims

T.S Eliot wrote ‘Humankind cannot bear very much reality’ this applies particularly to looking at the effects of mental heath treatment. In 1751 the scientist and Quaker, Benjamin Franklin petitioned the Pennsylvania colonial assembly for funds to build a hospital on the grounds that ‘it has been found , by the experience of many years, that above two thirds of the Mad People received into the Bethlem Hospital in England  and there treated properly , have been perfectly cured’. He was reiterating claims made in published books by English doctors. Fast forward over 260 years, to 2012 and an editorial in the prestigous journal Nature declares IAPT ‘represents a world-beating standard thanks to the scale of its implementation and the validation of its treatments’ (p. 473)’.  A decade later, NHS England echoes this declaring ‘the Improving Access to Psychological Therapies (IAPT) programme began in 2008 and has transformed the treatment of adult anxiety disorders and depression in England. IAPT is widely-recognised as the most ambitious programme of talking therapies in the world and in the past year alone more than one million people accessed IAPT services for help to overcome their depression and anxiety, and better manage their mental health’ and recommends the IAPT Manual (2021). In 2019, Pickersgill examined the proliferation of IAPT by canvassing the views of professionals and professional bodies, noting that IAPT fellow-travellers were in the ascendancy. But in this evangelisation for the in vogue psychological interventions nobody has asked the consumer or considered the operation of vested interests.

The Absence of Open Discussion

Psychological disorders are ubiquitous and can negatively impact the course of coexisting physical conditions. Since the days of Benjamin Franklin, UK data on mental health treatment, has been used to foster the belief that UK treatments are a ‘world beater’. But independent evidence to support this contention is lacking. There is not just a gap between the psychological treatments delivered in randomised controlled trials and what comes to pass in routine psychological services, such as the Improving Access to Psychological Therapies Programme (IAPT) service, but a chasm. Efforts to have a meaningful debate on the issue have been met with a deafening silence. In the silence, the scope of psychological treatments has gradually been expanded, beyond the initial focus of depression and the anxiety disorders to include patients with long term physical conditions – a psychological imperialism. The power-holders definition of the outcome of routine psychological treatment reigns.

 

Dr Mike Scott

Nature (2012) Editorial: Therapy deficit. Nature 489(7417): 473–474.

Pickersgill M. (2019). Access, accountability, and the proliferation of psychological therapy: On the introduction of the IAPT initiative and the transformation of mental healthcare. Social studies of science49(4), 627–650. https://doi.org/10.1177/0306312719834070

 

 

 

 

 

 

Low Intensity CBT, ‘Penny Wise & £ Foolish’

Psychological Wellbeing Practitioners (PWPs) deliver the smallest dose of psychological interventions (low intensity CBT), less than 6 hours of contact per client (Shafran 2021). Making it cheaper than high intensity CBT. But there is little evidence that the PWPs ministrations make a difference the client would recognise. There are no randomised controlled trials of high or moderate quality (Cochrane Grade) that attest to low intensity CBTs efficacy. The PWPs are not psychological therapists, as such, most IAPT clients do not receive psychological therapy. The name IAPT, Improving Access to Psychological Therapies is therefore an example of doublethink. Here we have a classic example of false economy.

Low intensity CBT is intended to be the first step for those suffering from depression and the anxiety disorders, with PTSD and OCD clients going straight to high intensity interventions. Most clients first encounter low intensity CBT, should they not respond they are placed on a waiting list for high intensity CBT. In practice comparatively few, about 10%, are stepped up,  but with wide regional variations.It is not so much stepped care as stopped care.

Implementation of the ‘stepped care’ model costs the taxpayer of over a £1bn a year. But there has been no independent evaluation of the package or its components. IAPT is the first ANGO (an autonomous non- governmental agency) funded by the government, as opposed to the intended and understood QUANGO – a quasi autonomous non-governmental agency. Perhaps the National Audit Office and MPs might care to explain why there has been this failure of governance?

 

Dr Mike Scott