IAPT Haemorrhaging Clients

The latest IAPT figures for August 2018 show 60.3% of clients attending attending less than 2 treatment sessions. Under the auspices of NHS England IAPT claims to offer NICE approved therapies for treating people with depression or anxiety but the typical recommended dosage of such therapies is 10 or more sessions! Casualties are strewn in ‘no-mans land’. The National Audit Office (NAO) rather than publish the results of its’ investigation has chosen to look the other way. Yesterday the NAO was very vocal on another Government Quango, Motability but mental disability appears not to be as deserving of critique as services for those with a physical disability. If 60% of physically disabled people were not enabled to get the vehicle they require, there would rightly be an outcry, yet the majority of IAPT referrals are expected to suffer in silence. The IAPT figures can accessed using the link below:

https://www.dropbox.com/s/crucmhktn3r88ud/IAPT%20Figures%20for%20August%202018.pdf?dl=0

Notwithstanding this IAPT in its’ pilot projects is expanding ‘IAPT care’ into the medically unexplained symptoms (MUS) field (see link below). Despite the concept of MUS being jettisoned from DSM-5 [American Psychiatric Association (2013)] –  in a radical departure from its’ predecessor DSM IV it cautions that it cannot be assumed that just because no physical explanation is proferred the problem must be psychological. Nevertheless IAPT in its report on integrated services comes up with an ‘MUS recovery rate’!

https://www.dropbox.com/s/f1taewasjrg4pyw/IAPT%20MUS%20Aug%202018.pdf?dl=0

Dr Mike scott

Telling It As It Is at IAPT

There is an urgent need for an independent investigation of IAPT. In an earlier blog ‘IAPT half baked’, an IAPT worker commented that it would be ‘hair raising’ for people to learn of his/her experiences. This past week I’ve come across 2 cases that exemplify this,

  1. ‘X’  was given 3 sessions of guided self-help therapy, judged ‘resistant’, treatment was judged unsuccesful on the basis of PHQ 9 and GAD7 results and it was recommended that ‘X’ was stepped up to trauma focussed therapy. But without any specification of what the trauma was or its’ sequelae.  Some months later ‘X’ began a series of 10+ sessions at step 3 for Generalised Anxiety Disorder (GAD) , but during treatment the therapist discovered ‘X’ experienced  a very distressing incident many years ago and was upset when thinking about it. This event became the treatment focus and by the end of therapy ‘X’ was allegedly less distressed by this incident. Treatment was judged successful on the basis of changes on PHQ9 and GAD7 scores, but the therapist discharge letter said ‘ may now need to be re-referred for treatment of GAD!
  2. ‘Y’ saw his/her GP immediately following a needlestick injury was given the IAPT telephone number and a telephone consultation took place within days, PHQ9 and GAD7 scales were completed and the scores were elevated and ‘y’ was scheduled for a face to face treatment 6 weeks later. If you were not distressed/anxious after a needlestick injury you really would be weird, does the GP and IAPT have to collude in this medicalisation of normal distress, is this really a proper use of resources? from a GP’s point of view I can see that it ‘off loads’ a case for a time but really!

My fear is that no one in power really wants to know what is going on at the coal face, it is not helped by the National Audit Offices failure to publish the results of its investigation into IAPT. One can only speculate that the champion’s of IAPT, NHS England have had a gentle word with the Office.  The effect is that a political correctness rules expressing concern about mental health, stigma and the need for more resources, but without getting close to the people effected and really listening to what is going on.

 

 

Dr Mike Scott

Antidepressant Usage Challenges CBT Treatment

CBT clients often wish to discuss discontinuation of their antidepressants or take precipitous action to do so. But CBT training rarely addresses such issues. The matter has been  given an extra urgency by a recent paper by James Davies and John Read which found that that half of antidepressant users have significant side effects when they attempt withdrawal., see link

https://www.dropbox.com/s/rs6x0hapwduccgz/antidepressants%20Davies-Read%202018.pdf?dl=0

But these withdrawal symptoms can be labelled as a return of anxiety/depression, a misdiagnosis and the GP then increases the dosage or switches the person to another antidepressant. Clients often then complain of being ‘zonked out’ and an increase in symptoms particularly impaired concentration, making CBT more difficult. The danger is that the CBT therapist can feel that they are on uncertain ground, marginalise the client’s medication concerns and hurriedly revert to whatever protocol was being followed. Unfortunately the therapist and GP are most likely located in different laces with no opportunity to chat about such matters.

The NICE guidelines for GPs states that withdrawal symptoms for antidepressants last a week or two after gradual withdrawal. but this advice was based on studies where patients had been on antidepressants for just 8-12 weeks.  Davies and Read point out that over half of those on antidepressants have been taking them for more than 2 years and suggest that this is a very different ball game, with withdrawal symptoms beginning some time after discontinuation. They call for more real world studies of the discontinuation of long term antidepressants.

In the light of the Davies and Read paper NICE is reconsidering its guidance to GPs.

 

Dr Mike Scott

Clinical Commissioning Groups Not Listening To GP’s on IAPT – The Chaos of Liverpool

Earlier this month Pulse reported ‘In Liverpool, Dr Barnett (GP) says services last year ‘couldn’t have been much worse’ and ‘GPs did not bother to refer patients [to IAPT] because nothing would happen’. Yet the Liverpool Clinical Commisioning Group in its report ‘Talk Liverpool Contract’ dated July 10th 2018 talked of a steady improvement of IAPT’s performance such that it fell just short of the target 50% recovery rate!  Via my MP Maria Eagle I complained that my own independent study of 90 former IAPT clients showed an overall 9.2% recovery rate. https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

The Chief Operating Officer,  for Liverpool CCG, Mr Ian Davies replied simply re-iterating IAPT’s national claims.

It is clear that when CCGs talk to IAPT Managers the discussion is about operational matters e.g number of client’s seen, waiting times etc and never about whether the Service makes a real world difference to patient’s lives. CCG’s have blindly taken on board IAPT’s own metric of recovery and its’ assessment of meeting targets, there would never be such incredulity about a drug. NHS Foundation Trusts ought to be challenging this naivety.

Dr Mike Scott

Unannounced Visits To IAPT Reveal……..

The Care Quality Commission (CQC) pay unannounced visits to establishments for vulnerable people and have thereby revealed tragedies such as Winterbourne View in 2011.  But the clients of IAPT are no less vulnerable, yet there is no inspection on their behalf.  I wonder what the CQC would make of a lady on the autistic spectrum accepted into IAPT for management of her anxiety,  catered for by a high intensity therapist who is allowed only 6 sessions, with no knowledge of autism or of the grey are between OCD rituals and aspects of autism.  The CQC would surely cry foul, but this is not an isolated example.

If IAPT practitioners are to be based in GP practices they could fall within the CQC’s orbit of ‘people with poor mental health’.  Had they visited the establishment where   the would be Bake Off winner,          Kim-Joy https://www.theguardian.com/tv-and-radio/2018/nov/12/i-was-preety-much-mute-at-school-the-bake-offs-kim-joy  worked they would have heard her tell, that she has a Master’s in psychology, she could provide only up to 6 half hour sessions in low intensity and was heading off to other pastures.  If they needed an independent window on what is going on in IAPT I would have given them the following comments from amongst the 90 clients that I saw:

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

There are valuable TV programmes such as ‘GPs Behind Closed Doors’, I wonder what the public would make of ‘;IAPT Behind Closed Doors’ but such a programme would have to escape censorship by NHS England (and IAPT leadership)  something GPs would not tolerate.

Dr Mike Scott

IAPT Half Baked

IAPT dominates mental health provision, so you have to be free of its’ clutches to voice dissent.  The        Guardian reported on a  dissident (see link below) ” Before Bake Off, Kim-Joy was a psychological wellbeing practitioner, having done a master’s in psychology………but I’m at a point where the clinical side of mental health isn’t for me. You do a questionnaire with each person when they come in. So they tell you how many times that week they’ve felt low, which is a really weird question. It’s not real. Professionals need it for their data, to see who’s recovering. A lot of people just make up their answers, because they want to sound like they’re feeling better.”
We need an ever rising chorus of dissidents for clients not to continue to suffer in silence. There has to be a commitment to honesty and not fake news e.g ‘51% recovery’. The silence over the true                    functioning of IAPT clients is eerily reminiscent of the silence over ‘shell shock’ in the two world wars.
Dr Mike Scott

IAPT’s Bonfire Night

Yesterday Pulse published its’ investigation of IAPT, it was the effigy on the bonfire despite NHS England’s protestations, see link below:

https://www.dropbox.com/s/f19vxn1h4kd37bf/IAPT%20Bonfire%20%20Night%20Revealed_%20How%20patients%20referred%20to%20mental%20health%20services%20end%20up%20back%20with%20their%20GP%20_%20Article%20_%20Pulse%20Today.pdf?dl=0

It follows close on the heels of the BBC investigation., see link http://www.bbc.co.uk/news/health-45895541

What is still not properly recognised is that despite over £1billion being spent on IAPT there has been no independent assessment and my work suggests just a 15% recovery, it is a scandal.

 

Dr Mike Scott

 

Beyond the Stigma of Mental Health

If the stigma of having a mental health problem was abolished overnight, it wouldn’t make a real world difference to the daily life’s of any of the enormous  numbers of sufferers that I know. Being against stigma is like being against war, desirable, but no guarantor of functioning. Politicians and Prince’s rightly clamour to be against the stigma surrounding mental health problems but it is delusional to think this has or could determine recovery from any recognised disorder. The clamour is often associated with the promise of more monies for mental health.  This is  given a cautious welcome by providers of mental heath services, but with a muttering  of ‘yes but it is not enough, we need (an unspecified sum)  to expand’. There is a steadfast refusal to acknowledge that even those currently treated are ill-served.

In my recent BBC TV interview (October 19th) I made the point that there is only a 15% recovery in the IAPT service, a total abscence of independent assessment despite spending over £1billion on the service, initial assessments by telephone by the least qualified clinicians, resulting in treatment built on sand. IAPT declined to be interviewed and simply re-iterated its’ party line, with no attempt to critique my findings.   This has been followed by a deafening silence, what does this betoken?

 

Dr Mike Scott

We Need a ‘Cochrane’ To Evaluate Routine Practice

Cochrane reviews are often used as a ‘gold standard’ for establishing whether a treatment can be regarded as efficacious. They are independent of practitioners/researchers. But they don’t always get it right, for example on the appropriateness of graded exercise for chronic fatigue syndrome (CFS). Nevertheless there is a re-consideration of conclusions in the the light of the critique of others and they are for example going to post a qualifying note about their original conclusions on CFS. Whilst others including myself would wish that their original report was withdrawn, nevertheless one feels that there is an openness and objectivity. By contrast when it comes to evaluating whether treatments are effective in routine practice, as in IAPT, there is no such ‘Cochrane’, it feels much more like voicing dissent in some totalitarian regime. Those in power dominate the media, refuse to directly and openly debate and the juggernaut roles on, until one day it will implode and people will wonder why the writing on the wall was not heeded earlier!

Dr Mike Scott

BBC Investigates IAPT – A Stepping Stone To Accountability

On Friday the BBC TV broadcast an interview with me in which I said IAPT’s recovery rate was just 15%, this contrasts with IAPT’s claim of a 50% recovery rate, arrived at by marking their own  homework. Further I noted that using IAPT’s own data there is a threefold  difference in recovery rate by geographic area, if there were such differences in outcome with heart bypass surgery it would be thought that something was seriously amiss.  It is great that the subject of IAPT has finally come under public scrutiny but Clinical Commissioning Groups, MPs, and professional bodies have to put IAPT in the dock and question whether the £1bn expenditure on it has been justified. That there has been no funded independent assessment is an ongoing scandal.

The BBC Investigation  can be accessed using the  following link

http://www.bbc.co.uk/news/health-45895541

interestingly IAPT focussed the BBC’s attention on the 1 in 7 geographic areas that fail to reach its’ 50% yardstick, rather than that only 1 in 7 of its’ clients overall recover.

 

Dr Mike Scott