What If IAPT Had Never Happened?

Ten years on from the inception of the Improving Access to Psychological Therapies Service (IAPT), it is important to  review what would have happened but for IAPT. Using this comparison (what economists term the appropriate counterfactual), it is far from clear that IAPT has conferred any advantage and it is extremely doubtfuI whether the £1.3 billion spent on it has been worthwhile. Perhaps in the New Year IAPT should be renamed Impoverished Access to Psychological Therapies!

More about this anon.

 

Happy New Year

 

Dr Mike Scott

IAPT and Rudolph

Rudolph had a very shiny nose, in a routine consultation with  his GP, Dr Touchy-Feely, the latter said that it was medically unexplained and he could be referred/or refer himself to IAPT.

He replied that it was a long term physical condition and he didn’t think a psychological service was appropriate. The GP opined that he might have persistent somatic symptom disorder and entered this in his notes. . Later that day Rudolph had a telephone conversation with Father Christmas who wondered whether he could help him out that evening. Rudolph mentioned in passing his conversation with the  GP. Father Christmas observed that everyone knew he had a very shiny nose and could on occasion feel left out or ridiculed but was this really a psychological problem, didn’t IAPT have enough to do with all the anxious and depressed people! Rudolph replied sheepishly, perhaps I should ring IAPT in the New Year, after all the GP is saying I have got persistent somatic disorder. Father Christmas replied Dr Touchy-Feely, does not know what evidence based criteria are for anything and added whimsically ‘he doesn’t even believe in me’.

Have a great Christmas Folks

 

Dr Mike Scott

Involved In A Fatal Road Traffic Accident And IAPT Offers A Telephone Assessment

Paula (not her real name) was involved in a fatal road traffic in which her mother  died. Her GP referred her to IAPT, 6 months later she received a telephone call from them to arrange a telephone assessment.  She declined the telephone assessment, felt they were ticking boxes and was told it would be a further 2 month to wait for a face to face appointment.  So this is what is meant by IAPT care! When I saw Paula she was in tears throughout much of the session, had trauma related  guilt with regard to the rta and was suffering from depression and mild PTSD.  IAPT could do with the Christmas message of hospitality, but not just for Christmas.

May the peace and joy of Christmas be with you

 

Dr Mike Scott

Shambolic Mental Health Treatment for Children

An independent rigorous assessment of children’s mental health services is long overdue, wake up National Audit Office! Therapists are navigating children through a fog. Paula, not her real name, a 6 year old, had a traumatic incident at a fair and suffered separation anxiety  disorder. She had 6 treatment sessions with CAMHS, she was discharged on the basis of ‘low chance suffering from post traumatic stress’  and recalling the event with ‘no distress’.   But having seen her myself and assessing her using a standardised diagnostic interview she never did suffer from PTSD and the separation anxiety disorder has not been systematically addressed. Nevertheless the therapist calls for the whole family to attend ‘family systemic therapy’, notwithstanding that Dad does not live with them and sees mum as irresponsible for taking her to the fair. Mum sees this as just a further example of his being a ****** and is unphased by this!

The current zeitgeist is to ask for more resources for children’s mental health, putting mental health workers in school etc.  The idea is that adult mental health problems could be prevented by such actions but the evidence base on this is at present weak. But even in the unlikely event of extra resources being delivered,(as opposed to promised), if we multiply very poor treatment you still get very poor treatment.  It is crucially important to clarify the landmarks that child and adolescent therapists should use to assist children and their caregivers through the fog.

Charities often link up with formal bodies to provide services, but they are often a) desperate for funding and b) don’t have the training (or wish) to measure real world outcomes. Perhaps the best Christmas gift to children would be a truly independent and rigorous assessment of the psychological treatment they receive. This is not at all to marginalise the importance of support groups for children and adolescents with a wide range of problems.

Dr Mike Scott

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