All CBT Interventions Are Winners And Must Have Prizes!

This is the Alice in Wonderland take home message from IAPT workshops, BABCP conferences and CBT courses. But beyond depression and the anxiety disorders outcomes are fudged, massaged for public consumption.

At best admission to a randomised controlled trial is based on meeting the DSM criteria for the disorder. But there is no symmetry, outcome is not based on not meeting the criteria at the end of treatment. Instead dubious definitions of ‘remission’ and ‘recovery’ are used, which obfuscate whether there has been a real world change in the client’s life. It is impossible to determine whether or not they are back to their usual self.

By way of example Troscianko, in the May 2018 issue of Psychology Today, looked at CBT for bulimia, see link below:

https://www.dropbox.com/s/uax6pn3ctmefq4o/Eating%20Disorders.docx?dl=0

she points out that the CBT outcome studies for bulimia use a criterion for remission as bingeing/vomiting less than twice a week for 28 days and recovery as not bingeing/vomiting for 28 days. Yet the DSM diagnosis of bulimia requires duration of the disorder of at least 3 months, transparency requires a similar period to obtain for recovery. The published results cite a 45% recovery rate but the small print indicates that this actually refers to a 28 day period. Further 30% of those who ‘recovered’ relapsed in a year, this casts doubt on the original definition of recovery. In addition the ‘positive’ findings have not been replicated by researchers independent of those who developed the protocols.

Matters become more Alice In Wonderland when studies are conducted , without the DSM criteria, for example in the case of chronic fatigue syndrome see link below

https://www.dropbox.com/s/j19ryolg1ayxzg1/Baraniuk%20Chronic%20fatigue%20syndrome%20prevalence%20is%20grossly%20overestimated%20using%20Oxford%20criteria%20%281%29.pdf?dl=0

and there are prepostorous claims for success which evaporate when objective measures are used. This does not bode well for the development of an evidence base f or IAPT’s work with medically unexplained symptoms (MUS) and long term physical conditions (LTC’s). Doubtless there will be proclamations of success , but the yardsticks need to be published in advance and agreed before IAPT’s marketing exercise gets underway.

Dr Mike Scott

Missing The Boat With A Focus on Pressing Concerns

As a matter of respect clinicians necessarily focus on a client’s pressing concerns, but the time constraints imposed by routine services, such as IAPT, means that this becomes the sole focus. The upshot is that initially the client’s focus is say on their depression but at the next appointment on disturbing flashbacks/nightmares of child abuse and at the next appointment they may mention occasional excessive use of alcohol causing arguments at home. The clinician doesn’t know where they are working is this depression? PTSD? relationship problems/ alcohol dependence? or some combination thereof. This means the clinician is unable to help the client navigate through the fog of their difficulties, changing tack with every gust of wind.

Alternatively the clinician might simply pursue the first disorder ‘identified’ because the client doesn’t mention any other, discharging the client at the first signs of an improvement on some psychometric test or when progress has been made on that disorder. Despite the client actually suffering from a number of other disorders, making any gains in the ‘successful’ domain likely short lived. The client’s then go thru a revolving door. It seems that clients are rarely asked ‘are you back to your usual self following this treatment? and importantly ‘how long have you been back to your usual self for? [ anything less than 8 weeks is likely nothing more than the waxing and waning of the natural course of a client’s symptoms].

One of the ways of getting the bigger picture is to first use an open ended interview that contains the screen below, the dropbox link for this

APPENDIX A. SCIP screening questions
Codes: 0=absent, 1=present, 8=unsure, 9=missing data, unless otherwise
specified in the question
Questions apply to the present episode, typically the past month, unless otherwise
specified by the interviewer.
HAVE YOU:

  1. Felt very anxious and afraid out of proportion to the situation (with or
    without physical symptoms) for more than one month?
  2. Had panic attacks, when you suddenly felt anxious and frightened and
    developed physical symptoms, such as fast heart beat, shaking, or
    sweating?
  3. Been afraid of going out of the house alone, traveling alone, being alone,
    being in crowds?
  4. Been afraid and anxious doing things in front of people, such as eating in
    public, speaking in public?
  5. Had unpleasant and unwanted thoughts or images coming into your mind
    over and over even if you try to get rid of them? Examples: Contamination
    or aggressive, sexual, or religious thoughts.
  6. Had the urge to do things over and over and could not resist doing them
    (such as washing your hands even if they are clean, checking doors,
    counting up to certain numbers, reciting phrases)?
  7. Witnessed or experienced a traumatic event that involved actual or
    threatened death or serious injury to you or someone else (e.g., physical or
    sexual abuse, terrorist attack, natural disaster, war)? Did you feel intense
    fear and helplessness?
  8. Re-experience the traumatic event in the last month in a distressing way
    (flashback, nightmare)?
  9. Had physical symptoms or physical illness for which doctors did all
    necessary work up and could not find medical explanation?
  10. Had pain and your doctor did all necessary work up and could not really
    explain?
  11. Worried about gaining weight to the point that you self-induced vomiting,
    or used diet pills, laxatives, or heavy exercise?
  12. Eaten a large amount of food within an hour or so, that is binge eating?
  13. Felt or described your mood as sad, downcast, gloomy, low in spirits, or
    depressed?
  14. Been unable to enjoy things like walking, working at your hobbies, or
    socializing with friends as usual?
  15. Had thoughts about harming yourself or even made an attempt at suicide
    (Include whether thought was due to depression or not)?
  16. Felt very happy, elated without reason, or very irritable without reason?
  17. Had mood swings: periods of depression and elation or irritability?
  18. Felt that people are spying on you, follow you around, talk about you?
    Felt that there is a plot or conspiracy against you?
  19. Felt that people are trying to harm you or poison your food?
  20. Had experiences of hearing voices or noises that other people cannot hear?
  21. Had experiences of seeing things (images, flashes, shadows, objects,
    people, whole scene) that other people cannot see?
  22. Been violent in the past (with or without the influence of alcohol or drugs)?
  23. I would like to ask you questions on alcohol use over the past year:
    A. On days when you drank, did you drink >5 alcohol drinks per day
    (sometimes)?
    B. Did you have any problems resulting from drinking alcohol?
  24. I would like to ask you questions on illicit drug use (e.g. marijuana) over
    the past year:
    A. Did you use the illicit drug >10 times per month?
    B. Did you have any problems resulting from using the illicit drug?

is also below:

https://www.dropbox.com/s/j5rfmy6hthp6142/Reliability%20of%20Diagnoses%20SCIP.pdf?dl=0

then when you have an idea of possible diagnoses you can make systematic enquiry about all the symptoms of that disorder using the diagnostic questions in Simply Effective CBT Scott (2009).

In my view the poor results for therapy in routine practice is often because the therapist doesn’t know what they are dealing with rather than therapeutic competence per se.

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

Dr Mike Scott

Mental Health Systems Not Fit For Purpose

The promise of evidence based CBT treatments and antidepressants seems not to be realised in practice, an editorial in the current issue of the Canadian Journal of Psychiatry notes:

‘Despite a 3- to 4-fold increase in the use of antidepressant
medications, the prevalence of depression and anxiety dis
orders in Australia, Canada, the United Kingdom, and the United States has remained unchanged over the past .1 20 years In the absence of compelling evidence that the incidence of these disorders is on the rise, a natural conclusion is that depressed or anxious patients who could benefit from treatment are still not identified and treated, or that the duration of illness has remained unchanged in those who are treated. This is a striking and troubling finding, considering the known efficacy of antidepressants and psychotherapies. It emphasizes both a well-delineated treatment gap, whereby many patients with depression or anxiety do not receive treatment, and a quality gap whereby those who are treated either do not need to be treated or do not receive effective 2-7 treatment’. Click link below for full editorial: https://www.dropbox.com/s/kbmly9awq9diflb/Collaborative%20Care%202018%20mediocre%20usual%20care.pdf?dl=0

  1. Jorm AF, Patten SB, Brugha TS, et al. Has increased provision
    of treatment reduced the prevalence of common mental disorders?
    Review of the evidence from four countries. World Psychiatry.
    2017;16(1):90-99.
  2. Jorm AF. The quality gap in mental health treatment in Australia.
    Aust N Z J Psychiatry. 2015;49(10):934-935.
  3. Lin EH, Katon WJ, Simon GE, et al. Low-intensity treatment of depression in primary care: is it problematic? Gen Hosp
    Psychiatry. 2000;22(2):78-83.
  4. Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in
    primary care: a meta-analysis. Lancet. 2009;374(9690): 609-619.
  5. Simon GE, VonKorff M, Wagner EH, et al. Patterns of antidepressant
    use in community practice. Gen Hosp Psychiatry. 1993;15(6):399-408.
  6. Kendrick T, King F, Albertella L, et al. GP treatment decisions
    for patients with depression: an observational study. Br J Gen
    Pract J R Coll Gen Pract. 2005;55(513):280-286

But the editorial posits that greater collaboration between services would usher in the promised land. Whilst this might be helpful, a failure to understand what constitutes a faithful translation of the positive results of randomised controlled trials for depression and the anxiety disorders [see Scott (2017) Towards a Mental Health System That Works London: Routledge https://www.amazon.co.uk/Towards-Mental-Health-System-Works/dp/1138932965/ref=sr_1_1?ie=UTF8&qid=1547819366&sr=8-1&keywords=Towards+A+Mental+Health+System] into routine practice will continue to nullify any actions. Unfortunately in the UK, IAPT continues to pursue its own fundamentalist translation of the randomised controlled trials, despite evidence that it doesn’t work, with just a 15% recovery rate [ Scott (2018) see link below:

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

Further IAPT has extended its’ empire well beyond the borders of reliable evidence based outcome studies e.g to medically unexplained symptoms. Staff are frightened to speak out publicly. It is difficult to escape charging IAPT with imperialism. Theirs is a dominant narrative in BABCP, British Psychological Society and in journals such as Behaviour Therapy and Research.

Dr Mike Scott

‘Optimal Outcomes Are Not Being Obtained Using Current Gold-Standard , Trauma Focused Interventions…..’

according to a recent editorial in the American Journal of Psychiatry, by Dr Robin L Aupperie, he continues ‘evidence is mounting that non trauma focused therapies may have at least equal efficacy for the treatment of PTSD’. See the link below:

https://www.dropbox.com/s/aexz30a6t04apen/PTSD%20%20trauma%20focussed%20CBT%20dogma%202018.pdf?dl=0

he points to only 30-40% of veterans with PTSD losing their diagnostic status following trauma focussed cbt. Dr Aupepperie raises doubts about ‘the presumed essentiality of trauma processing for the effective treatment of PTSD’. I have also raised doubts about it in a paper ‘PTSD an Alternative Paradigm’ which is under submission.

But there is a need to tread carefully in that there needs to be replication studies of the non-trauma focussed interventions in real world settings i.e not just with patients volunteering for a treatment, and across a broad range of settings i.e civilian and military. Nevertheless it does raise an eyebrow when a study comparing 8 individual sessions of mantram therapy with 8 individual sessions of present centred therapy [ Borman et al (2018) Am J Psychiatry, 175:979-988] concluded that 59% of the former no longer met criteria for PTSD at 2 month follow up compared to 40% in the latter. However psychology in general is replete with studies that have not been replicated [ Chris Chambers The 7 Deadly Sins of Psychology (2017) ‘After spending fifteen years in psychology and its cousin, cognitive neuroscience, I have nevertheless reached an unsettling conclusion. If we continue as we are then psychology will diminish as a reputable science and could very well disappear’] because positive outcomes are more likely to be published [ the file drawer problem] and the originators of a theory/intervention tend to be very charasmatic, creating a placebo effect. I have a feeling that the replication crisis is not taken as seriously in clinical work, with a paucity of studies in real world settings, using ordinary therapists and employing gold-standard assessments.

Just a footnote: the mantram therapy involved the repetition of a spiritually meaningful word, initially in non stressful situations e.g before bed, then applying this flashbacks and when woken from nightmares. The idea is to slow down thoughts and induce relaxation. The present centred therapy discusses current stresses and the problem solving of them in a non formal way. But in neither intervention was there a trauma focus.

Dr Mike Scott

IAPT’s The Solution, So What Is The Problem?

IAPT specialises in poorly defined problems, making it easy to claim success. Good marketing ensures its’ claims are taken on board by politicians and NHS decision makers. None of the problems it addresses have been as sharply defined as necessitated in the randomised controlled trials of CBT. Dealing in fuzzy problems leads to trading in fuzzy outcomes.

This fuzziness makes it easier for practitioners to convince themselves they are doing a good job. For example remembering in graphic detail a case that worked and ignoring the many failures (the operation of the availability heuristic). But it all begins to lack credibility when there are high levels of burnout (68% in low intensity and 50% in high intensity) and a 22% annual staff turnover in low intensity. In addition some staff are subjected to league tables, incentivised to perform better by the promise of extra holidays and told to limit sessions to six.

IAPT’s original remit was depression and the anxiety disorders, but these terms had a very specific meaning in the rct’s. The boundaries of these disorders were defined by what Aaron Beck termed controlling for information variance (the range of symptoms considered pertinent for a particular disorder) and criterion variance (whether a symptom was present at a level that constituted impairment) as gauged by a standardised diagnostic interview. Neither type of variance has been addressed by IAPT, instead it has developed its own fundamentalist definition of what anxiety and depression are, eskewing reliable diagnosis. IAPT’s fuzziness has reached a new level as it extends its’ scope to medically unexplained symptoms, despite the injunction from DSM5 that just because something is medically unexplained that is not sufficient basis for saying that it is psychological.

IAPT marches ever on, perhaps it can ‘solve’ BREXIT

Dr Mike Scott

Where IAPT Has Never Happened, No Evidence Of Worse Outcome

Clinical Commissioning Groups (CCG’s) should consider why other parts of the UK have not followed England’s lead on IAPT, after more than a decade. Wales, Scotland and Northern Ireland  have remained unimpressed by IAPT’s groundbreaking claims and have not followed suit.  In Wales almost 40% of people surveyed said ‘yes’ or ‘mostly’ when asked had the services they accessed led to improved mental health and wellbeing  [Gofal (2016) Peoples experiences of primary mental health services in Wales Three Years On].  The results show that the largest proportion of respondents (79%) were offered prescription medication. The proportion of people who felt that they has been offered advice and information was 77%. 21.5% were offered Cognitive Behavioural Therapy, while 32% were offered another form of psychological therapy. 36% were offered a further mental health assessment. 26% were referred to another service and 17% were signposted to another service. Just 12% were offered physical exercise, 10% were offered books on prescription and 3% were offered befriending. If you have a mental health problem in Wales it is not obviously worth the trip across the border to an English IAPT service.

There are undoubtedly serious problems with mental health services across the UK, but these are no less in England despite IAPT. .

Dr Mike Scott

‘Attempts to Justify The Cost-Effectiveness of IAPT…Severely Lacking’

this is the conclusion of a recently published study in the Journal of Health Psychology

https://doi.org/10.1177%2F1359105318803751

Scott Steen, the author of the the new cost-benefit analysis, comments ‘The first limitation concerns the high proportion of early disengagement which, according to the latest annual report, around 40 per cent of those entering treatment attend one session only (IAPT, 2018). Within the same annual report, approximately 43 per cent of assessed-only referrals were deemed suitable but declined treatment, while
23 per cent were deemed not suitable, and only 9 per cent were discharged by mutual agreement following advice and support (IAPT, 2018). The second limitation concerns the heavy reliance on brief, self-report measures and lack of long-term outcomes which, when using more in-depth and longitudinal techniques, have found intervention effects to be diminished or even temporary (Ali et al., 2017; Cairns, 2013; Hepgul et al., 2016; Marks, 2018; Scott, 2018)’.

Steen continues ‘research used to justify the economic benefits of the IAPT programme has little relevance for how it delivers and evaluates interventions. For instance, Layard and Clark (2014) cite a study conducted by Fournier et al. (2015) to justify the potential rate at which individuals move from incapacity benefits into employment. However, this specific study focuses only on patients who had recovered from severe depression, were assessed using structured clinical interviews and diagnostic criteria, and were treated by highly trained practitioners, the majority of whom had PhDs. Similarly, research into the long-term effects of interventions appears to have been selectively chosen, omitting the generally limited to mixed findings in this area (Marks, 2018)’.

In summary Steen opines:

Taken as a whole, the IAPT programme seems to be delivering treatment at an inefficient cost. Although outcome targets are being reached, this appears to be due to an increased emphasis on low-intensity styled provision which not only drives up costs-per-IAPT outcome but also potentially reduces the appropriateness of treatment allocation and sustainability of these outcomes’.

All CCGs should be asked to consider this study.

 

Dr Mike Scott

Without IAPT, The Same ‘50%’ Recovery Rate – Why Do CCG’s Fund It?

One of IAPT’s criteria for claiming patient recovery is shifting a patient’s PHQ9 score to less than 10. But in a study by Gilbody et al (2015) [ see link below] involving 179 patients undergoing treatment as usual in primary care with an initial diagnoses of depression and PHQ9 scores of above 10, 101, (56%) of patients recovered within 4 months. [ A study of treatment as usual cases by Moore at al (2012) similarly showed a 47% recovery].  IAPT currently claims a 50% recovery rate, the burden of proof is on IAPT to demonstrate that it produces results significantly different to those treatments engaged in before its’ inception.

Even when the metric is an adequate treatment response the differences between IAPT and treatment as usual (TAU) are not apparent. In the study  by Moore et al (2012) [see link below] of 576 TAU cases of depression who completed the PHQ9 twice (mostly within 3 months)  63% showed an adequate treatment response ( a drop of 5 or more points), this is not  discernibly different to IAPT’s findings.

CCG’s want it seems to be seen to be mindful of mental health, as their masters NHS England dictate, but don’t want to engage in effortful thinking in this domain, bypassing it by talking only of operational matters, numbers, waiting times etc.  It is a new political correctness that also permeates the political parties.

The true metric of recovery is returning a person to their usual self ( a minimum component of which is losing diagnostic status, assessed independently), IAPT has studiously avoided  such a hard outcome measure preferring its’ own surrogate. All this despite that the original randomised controlled trials for anxiety and depression insisting on hard outcome measures.

 

Unfortunately mental health charities are often now dependent on IAPT and private agencies seek to ape IAPTs metrics, the upshot is that for the past decade there has been precious little evidence based psychological treatment of the sort I advocated in Simply Effective CBT London: Routlege (2009).

https://www.dropbox.com/s/awwtpdhv0mxbtht/Treatment%20as%20usual%20recovery%20rate%202015%20Gilbody.pdf?dl=0

https://www.dropbox.com/s/mupj14fq14eba4g/Depression%2050%25%20natural%20recovery%20on%20PHQ9%20within%203%20months%20of%20GP%20diagnosis.pdf?dl=0

Dr Mike Scott