IAPT – Discrimination and Incredulous Claims

Dr Michael Kelleher, a Consultant Addictions Psychiatrist, interviewed in next months Psychologist has claimed ‘some IAPT services exclude patients that use or have used alcohol until they are many months post abstinent. This is contrary to positive practice guidelines that the National Treatment Agency brought out’ . He continues ‘if people get detoxed they shouldn’t have to wait an arbitrary length of time to be sober before they can have psychological therapy. They should be able to flow into an anxiety or depression programme straight away once a detox is completed’.

IAPT data on 16,723 clients in the North East of England, Boyd, Baker and Reilly (2019), see link below, suggests that the Organisation is superb at spurning those with an alcohol problem,

https://www.dropbox.com/s/q1120m0cbvqb882/IAPT%20Stepped%20care%20model%202019.pdf?dl=0

over a 4 year period the proportion of clients treated with ‘a mental and behavioural disorder due to alcohol use’ never rose above 0.1%, ( 1, 1, 4 and 3 people in successive years). By contrast the proportion with ‘mixed anxiety and depressive disorder’ was 26.8%, 30.5%, 30.1% and 39.6% over the four years.

Dubious Recovery Rate

The North East IAPT service claims a recovery rate of 40-49%, depending on which years are considered. With between a quarter and half of clients categorised as ‘mixed anxiety and depressive disorder’. However the IAPT Manual cautions against the use of the ‘mixed anxiety and depressive disorder’ label thus:

‘The ‘mixed anxiety and depression’ problem descriptor (ICD-10 code) should not be used unless the person’s symptoms of depression or anxiety are both too mild to be considered a full episode of depression or an anxiety disorder. Inappropriate use of the ‘mixed anxiety and depression’ problem descriptor may mean that patients do not receive the correct NICE- recommended treatment. For example, if someone has PTSD and is also depressed they should be considered for trauma-focused CBT as well as management of their depression, but this may not happen if they have been identified as having ‘mixed anxiety and depression’.

Given the common usage of an unreliable ‘mixed anxiety and depression’ label, is it at all credible that the recovery rate should approach IAPT’s claimed national average of 50%? It looks like massaging of data for public consumption.

Choose The Right Clients For Performance

The IAPT Manual published a year ago, see link below:

https://www.dropbox.com/s/pgmbsoqjqmq04qz/IAPT%20Manual%202018.pdf?dl=0

clearly and rightly, states that it would be inappropriate for IAPT staff to provide therapy for clients who arrive at a session intoxicated. But delaying treatment once detoxified, smacks of special selection so the agencies performance figures look good – akin to a school selecting the brightest pupils in the area.

Studies generally show that the prevalence of depression and adjustment disorder are about the same, and psychiatrists diagnose them as often as each other, but curiously over half of IAPT clients in the Boyd et al (2019) study are declared to have depression but the prevalence of adjustment disorder doesn’t rise above 0.6% in any year! Either IAPTs population is incredibly skewed or there is no reliability at all in their diagnostic labels, such that therapists don’t have a clue what they are treating!

Non-Declaration of Conflict of Interest In IAPT Studies

IAPT staff have a penchant for not declaring conflicts of interest in published papers, in the Boyd, Baker and Reilly (2019) paper it is written ‘The authors have declared that no competing interests exist’ , but the lead author presenting at a Conference in Amsterdam in May 2016 is described thus:

Lisa Boyd, IAPT service, Tees Esk and Wear Valley Mental Health Trust, UK Impact of a Progressive Stepped Care Approach in an Improving Access to Psychological Therapies Service: An Observational Study

Dr Mike Scott

IAPT’s New Direction – ‘maybe, shove them all through low intensity’

that’s the take home message from a just published IAPT study conducted in the North East of England by Boyd, Reilly and Baker (2019), see link below:

https://www.dropbox.com/s/q1120m0cbvqb882/IAPT%20Stepped%20care%20model%202019.pdf?dl=0

This would mean that those with PTSD and social anxiety disorder would first fall into the orbit of low intensity interventions. Never mind that there is no empirical evidence from randomised controlled trials that these disorders respond to low intensity interventions.

Boyd, Baker and Reilly (2019) reiterate the populist myth that there is ‘sound evidence of the efficacy of low intensity interventions’ . This only becomes true if one lowers the methodological bar as low as in their own study, which was reliant entirely on self-report measures administered outside the context of a reliable diagnostic interview. These authors cite a study by Bowers et al (2013) in support of the effectiveness of low intensity interventions but these authors acknowledge that a key limitation of their study was generalisability, because patients were not reliably assessed for depression, see link below:

https://www.dropbox.com/s/24qz5pdu6dfl0ce/Low%20intensity%20initial%20severity%20doesnt%20make%20a%20difference%202013.pdf?dl=0

If the North East of England study is taken on board by IAPT, there is less need to worry about clients being on waiting lists for high intensity treatments, because they are allegedly already getting something worthwhile! Who needs high intensity therapists?

IAPT’s research and treatment is conducted on another planet from the lived experience of clients. Take the case of Tara, she suffered from depression after a fall and from a phobia about tripping, that I established with a diagnostic interview. She then had 6 IAPT face to face low intensity sessions which were described as guided self help, 2 of these involved behavioural activation. Her PHQ9 scores stayed at 19/20, which was not significantly different to when I 1st saw her with a PHQ9 score of 21. Treatment made no difference at all, though she valued the opportunity to talk she was very upset after the sessions. Tara was then put on a 3-4 month waiting list for high intensity CBT. The documentation revealed that there had been no evidence of fidelity to an evidence based treatment programme for depression and no attempt to address her phobia. Initially she had a telephone assessment with IAPT.

There is a wholesale abscence of appropriate treatment in IAPT and in practice its’ stepped care model violates continuity of care. It should try listening to clients and subjecting itself to independent audit, instead of playing with large sets of meaningless numbers, to justify funding.

Dr Mike Scott

Routine Psychological Treatment Is Like A Car Being Revved Stuck in Mud

Marija has had OCD for 30 years since adolescence, her treatment included exposure and response prevention at the Institute of Psychiatry, many years ago. Her most recent therapist has suggested she try this again. But closer examination of her notes reveal that she simply felt better for some months after exposure and response prevention. When I asked her did she return to her usual self after exposure and response prevention she said ‘no’, but was 80% better for a while. Whilst exposure and response prevention is a NICE recommended treatment, at most only 50% recover. The NICE guidance can as applied to routine practice create a tunnel vision. She is a classic example of how clinicians stop at the first identified disorder. Whilst she clearly has severe OCD, there is no mention at all in the voluminous records that she has also been suffering from panic disorder, depression and illness anxiety disorder, all of which have gone untreated. Her son commented ‘I always knew there was more than just OCD’.

Marija was relieved that there was some new potentially beneficial therapeutic targets and that a ‘light touch’ with her OCD rather than ‘battling with my thoughts’ might be useful. She entered a different mode when I suggested a) that she had performed an experiment by not completing her rituals when she was asleep and found she came to no more harm than when awake and b) would not ring the local radio station to tell them that everybody must perform her rituals to stop harm coming to their loved ones c) she had performed rituals for a year as a 8 year old but when she gave them up nothing happened.

Marija has gone through a revolving door of mental health clinicians, which could have been stopped by a careful reassessment and history taking using a standardised diagnostic interview.

Dr Mike Scott

IAPT’s Class Answer to Improving Access

Use classes. Forget about disorders just call it ‘stress’. Offer something CBT flavoured and capitalise on time and the placebo effect to demonstrate an effect, label the package ‘good practice’. Encourage IAPT providers to write about it in the Cognitive Behaviour Therapist (the online BABCP Journal) special issue to be devoted to IAPT, introduced by the lead clinician in IAPT.

The Stress Control (SC) programme of White et al. (1995) is more of a public health intervention than a psychotherapeutic group. It is run as a night school class, and though there are questions and answers between attendees and presenters, personal problems are not discussed.

IAPT’s Implementation

In an IAPT implementation of the programme, at Step 2, Burns et al. (2015) had a mean group size of seventy-four and a range from twenty-three to 106, with six weekly, two-hour sessions. The programme consisted of week 1, introduction to psychoeducation and the cognitive behavioural model; week 2, management of physiology; week 3, management of mental events; week 4, management of behaviour; week 5, management of panic attacks and sleep; and week 6, self-care. At the end of each session, material for the next session was distributed containing homework exercises. At the final session, relapse prevention materials were distributed.

Outcome

Three quarters of the 1,062 clinical cases [PHQ-9 greater than or equal to 10 and/ or GAD-7 greater than or equal to 8] attended three or more sessions. Of those attending pure stress control alone 37% ‘moved to recovery’, defined as an improvement of 6 points on the PHQ-9 and 4 points on the GAD-7. With mean PHQ-9 scores for the clinical case sample reducing from 15.50 to 11.58.  Burns et al. (2015) claim that ‘SC appears comparatively clinically equivalent to other IAPT interventions’. However Gilbody et al. (2015) looked at how GP patients with a PHQ-9 score of greater than 10 fare with usual treatment, over a four-month period; their mean PHQ-9 score reduced from 16 to 9. It is thus not at all evident that the SC programme is of social significance.

The Case For Classes Is Built on Sand And A Distraction From Providing CBT That Makes a Real World Difference

The methodological quality of the SC studies are poor when assessed by the Foa and Meadows (1997) criteria, in that there are no clearly defined target symptoms, no diagnostic interview was conducted to establish which if any disorder the person was suffering from and the proportion ‘cured’ by the end of the intervention. Further there is no independent evidence that six or fewer sessions constitute an adequate dose of psychotherapeutic intervention.

Burns, P., Kellett, S. and Donohoe, G. (2015) “Stress Control” as a large group psychoeducational intervention at Step 2 of IAPT services: Acceptability of the approach and moderators of effectiveness. Behavioural and Cognitive Psychotherapy, 44, 431– 443. http:// dx.doi.org/ 10.1017/ S1352465815000491

Foa, E.B. and Meadows, E.A. (1997) Psychosocial treatments for posttraumatic stress disorder: A critical review. Annual Review of Psychology, 48, 449– 480.

Gilbody, S., Littlewood, E. and Hewit, G. (2015) Computerised cognitive behaviour therapy (CCBT) as treatment for depression in primary care (REEACT) trial: Large scale pragmatic randomised controlled trial, BMJ, 351, h5627. DOI: 10.1136/ bmj.h5627

Scott, Michael J. Towards a Mental Health System that Works: A professional guide to getting psychological help (p. 116). Taylor and Francis. Kindle Edition.

White, J., Keenan, M. and Brooks, N. (1992) Stress control: A controlled comparative investigation of large group therapy for generalised anxiety disorder. Behavioural Psychotherapy, 20, 97– 114.

White, J., Keenan, M. and Brooks, N. (1995) Stress control: A controlled comparative investigation of large group therapy for generalized anxiety disorder. Behavioural Psychotherapy, 20, 97– 114.

Williams, C., Wilson, P. and Morrison, J. (2013) Guided self-help cognitive behavioural therapy for depression in primary care: A Randomised controlled trial. PLoS ONE, 8( 1), e52735. DOI: 10.1371/ journal.pone. 0052735

Dr Mike Scott

IAPT and Special Measures

If IAPT were a Hospital, operating without any consideration as to whether patients are returned to their usual selves with treatment, they would likely be placed in Special Measures. IAPT has eskewed accepted definitions of recovery.

IAPT’s Meaningless Yardstick

If you are departing IAPT (or wish to commit professional suicide!) tell your IAPT manager/supervisor the psychometric test results are not measuring anything meaningful, they are simply impositions from above! IAPT claims that the psychometric tests it uses (PHQ9 and GAD7) measure clinically significant change/ recovery. But this is not true.

The validity of clinically significant change criteria relies crucially on whether the test used taps the same construct as the identified disorder1. IAPT’s use of the PHQ9 and GAD7 violates the requirement for construct validity, specifically as IAPT make no standardised reliable diagnosis it is a lottery as to whether the psychometric test matches the diagnostic status of the client. A client could be suffering from for example variously, no recognised disorder, an adjustment disorder, OCD, panic disorder, the changing scores on the PHQ9 and GAD7 would say nothing at all about the outcome of an intervention for these disorders. To compound matters in the IAPT set up it is not possible to know when these measures are actually tapping depression or generalised anxiety disorder in a particular client.

IAPT’s Idiosyncratic Use of Tests 

IAPT have never stipulated any criteria for enduring improvement. Therapists discharge clients as soon as their scores dip below casenness on a self-report measure, neglecting to consider that what is being observed is likely natural variation than any return by the client to their usual self. Matters are compounded because clients can complete the questionnaires to either please the therapist (particularly likely if completed in front of the therapist) and/or convince themselves that they have not wasted time in investing in therapy.

IAPT Training At Fault

CBT therapists per se are not trained in methodology – there is rarely any understanding of concepts such as construct validity, reliability, the limitations of psychometric tests, bias introduced into such tests by the ways in which they are administered or of accepted criteria for recovery. The deeply flawed IAPT training has arisen without a murmur of protest from the British Psychological Society and BABCP hierarchy. The rationale appears to be so long as IAPT secures increased monies for mental health services that is all that matters, this is a dereliction of care to both clients and therapists.

How Outcome Should Be Assessed

The passage of depressed clients through IAPT has never been judged by accepted definitions of response, remission and recovery2, 3.

Response is defined as a clinically meaningful improvement in depressive symptoms that has continued for a sufficient length of time (3 consecutive weeks) to protect against misclassification owing to symptom variation or measurement error2. Response is typically operationalised as an  improvement of ≥ 50% over pre-treatment scores.

Remission relies on a definition of an asymptomatic range, defined as the presence of no or very few symptoms. A person can be judged to be in the asymptomatic range only if neither of the two essential features of depression (sad mood and loss of interest or pleasure) is present and fewer than three of the additional core symptoms of depression are present2. Remission requires that the person remains in this range for at least 3 weeks, again to protect against factors such as natural symptom variation.

Recovery is defined as an extended length of time in remission, which has been operationalised as at least 4 months4.

The passage of anxious clients through IAPT has never been judged by accepted definitions of recovery4. In the Bruce et al (2005) study of the trajectory of anxiety disorders a participant was considered to have recovered from anxiety disorder if he/she experienced 8 consecutive weeks at psychiatric status ratings of 2 or less (Table 1). Subjects who met this condition were virtually asymptomatic for 2 consecutive months.

Table 1

2. Residual The patient claims not to be completely his/ her usual self, or the rater notes thepresence of symptoms of no more than a mild degree (for example, mild anxiety in agoraphobic situations).

1.  Usual self The patient is returned to his/her usual self, without any residual symptoms of the disorder. (The patient may have significant symptoms of some other condition or disorder; if so, a psychiatric status rating should be recorded for that condition or disorder.)

References

1.Fisher PL and Durham RC Recovery rates in generalized anxiety disorder following psychological therapy Psychological Medicine 1999; 29, 1425-1434

2. Dobson KS, Hollon SD, Dimidjian S, Schmaling KB, Kohlenberg RJ, Gallop RJ, et al. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. J Consult Clin Psychol 2008;76:468–77

3. Dombrovski AY, Lenze EJ, Dew MA, Mulsant BH, Pollock BG, Houck PR, et al. Maintenance treatment for old-age depression preserves health-related quality of life: a randomized, controlled trial of paroxetine and interpersonal psychotherapy. J Am Geriatr Soc 2007;55:1325–32

4.  Bruce SE, Yonkers KA, Otto MW, Eisen JL, Weisberg RB, Pagano M, Shea MT and Keller MB (2005) Influence of psychiatric comorbidity on recovery and recurrence in generalised anxiety disorder, social phobia and panic disorder: A 12 year prospective study. Am J Psychiatry 162:1179-1187.

Dr Mike Scott

Terrorfied By Bomb Attacks

Victims of terrorists attack may suffer from post-traumatic stress disorder, living in terror of a further attack. Treatment needs to change to help victims deal with their state of ‘terrified surprise’ [ Scott (In submission) PTSD – An Alternative Paradigm and Scott (2013) CBT for Common Trauma Responses London; Sage Publications]. Clients should be encouraged to swap the glasses gifted by the extreme trauma and through which today is seen as a ‘war zone’, for the glasses they wore the day before the trauma. Below is a handout to help terrorist attack victims gauge the actual personal threat level:

If you have been the victim of a terrorist attack and have PTSD as a consequence, you likely feel ‘there could be another attack anytime’. Life is spent avoiding anywhere remotely like the scene of the attack.  You probably also take flight at the sight of anyone or any object that reminds you of the attack.  Life is lived in a state of ‘terrified surprise’, jumping out of your skin at unexpected noises or sudden movements, perhaps getting angry when this happens. You repeatedly check for signs of danger, seek to minimise risk by for example keeping the exit in sight in enclosed spaces. This all comes to feel normal and that the only safe place is home, but home has actually become a ‘bunker’ and you get cross with others not staying in a ‘bunker’, relationships become strained and there’s an increasing sense of isolation.

  Numbers Murdered In Attack   Odds of Being Killed 1 in…   Numbers Injured  Odds   of being injured 1 in….
2016   97.3 million     19   3.5 million
2017     37   1.8 million   300   220,000
2018    0   infinite   3   23 million

The above odds should be contrasted with the far greater odds of being killed in a car crash at some point in your life, of 1 in 103  or as a pedestrian 1 in 556.

The chances of exposure to an extreme trauma at a public gathering are about 1 in 11,000. [ 6000 had people brought tickets for the Manchester Arena Concert in which 22 people died as a result of the bombing]. Would you bet on a horse in the Grand National at these sort of odds?

The real risk of danger from a terrorist attack is nothing like the PTSD sufferer imagines, the vividness of the memory sounds, smells, feelings of helplessness give a very distorted impression of the likelihood of being a victim. Life is then about daring to live as if you are not in this ‘hall of mirrors’/ ‘war zone’.

Dr Mike Scott

CBT, Cancer and IAPT

a just published study of CBT for depression in patients with cancer has shown no effect [ Serfaty et al (2019)]. Patients were given CBT by IAPT staff in addition to treatment as usual (TAU) and the results compared with TAU alone. Whether the outcome measure was the PHQ9 or Beck Depression inventory there was no difference in outcome, see link below:

https://www.dropbox.com/s/iitvhyk5eyqjmyi/CBT%20for%20depression%20in%20cancer%202019.pdf?dl=0

The results suggest more generally, that if IAPT’s performance was compared to TAU no difference would be found. The study also casts doubt on the wisdom of IAPT’s sojourn into treating long term physical conditions.

Problems With Engagement

The intervention comprised up to 12 individual sessions (either face to face or over the phone), but the mean number of sessions received was 4.7 and over a third (35.6%) did not take up any sessions. They were all patients expected to live for 4 or more months. Interestingly 60% of patients had a previous history of depression. Of 2224 cancer patients only 10% (230) were found suitable and consented to treatment.

Some Methodological Issues

  1. There was no blind assessment of outcome using the standardised diagnostic interview (MINI) that was used to assess whether a patient was initially clinically depressed.
  2. TAU is a poor comparator as it does not control for the attention and expectations generated by being offered a special treatment (CBT). The appropriate comparator should have been an active placebo
  3. Therapists were rated using the Cognitive Therapy Rating Scale Revised but there is no mention as to whether this predicted outcome.

But CBT Can Make A Real Difference In The Right Hands

At The Right Time

One of the authors of the above study Kathryn Mannix, A Palliative Care Physician, has written a stunning book, With The End In Mind

With the End in Mind: How to Live and Die Well

Her capacity to be with people is truly amazing, this clearly is not just a job, for example her use of CBT with a patient with breathlessness as he awaits a lung transplant (he has cystic fibrosis) is truly exemplary. But she is a very credible source of persuasion with a detailed knowledge of the difficulties of those in Hospice care. I would wholeheartedly recommend you read this book.

Dr Mike Scott