Populist Mental Health Myths

poor psychological therapy services are as much about populist mental health myths, as underfunding. Drill down beyond IAPT and NICE and you enter a sub atomic world very different to that of the orchestrators.

In the microscopic world people are concerned with:

‘will I get back to my old self with this therapy?’

‘what proportion of people like me, get over this with therapy?’

‘are the effects of therapy temporary or permanent?’

‘are you interested in and committed to me, or am I just a number?’

Moving up to the macroscopic world, real world outcomes are replaced by surrogates ‘a change on a questionnaire’ but without any certainty the questionnaire is measuring anything pertinent to what the person is suffering from! There is no independent assessment of outcome of routine practice.

Myth One: IAPT and NICE are at one

IAPT insists that it is NICE compliant, i.e its treatment protocols match the identified condition. But IAPT clinicians do not diagnose, instead they make a judgement using ICD 10 diagnostic codes, this weak surrogate ignores that NICE Guidance assumes a reliable diagnosis and advocates the DSM criteria not ICD10!

Myth Two: IAPT is credible because of its’ advocacy of NICE Guidelines

The NICE guidelines have called for a decade, for an evaluation of low intensity CBT vs counselling vs treatment as usual, which would include observer rating. Such is its’ ongoing uncertainty as to the value of low intensity CBT.

Myth Three: The value of low intensity CBT has been demonstrated

Not if one insists on methodologically strong studies involving independent outcome assessors.

Myth Four: CBT is the answer

NICE points out that even where there is the strongest evidence in favour of the use of CBT in depression the effects are ‘modest’. It also notes that there are comparitively few studies of Behavioural Activation (BA) and NICE makes a clarion call for more head to head research between BA and CBT. But stresses the need for inclusion of observer rated assessment in such a study, they also may have added that there is a need also for an attention control group. There is a need for more humility in IAPT about the contribution of CBT.

Myth Five: Approval by NICE equals evidence of efficacy

Not so, NICE guidelines are the fruits of a committee’s deliberations, about primarily, the results of randomised controlled trials, but there is no assessment of those rcts using the Cochrane risk of bias, which includes requirements such as observer rated outccomes.

Myth Six: IAPT never departs from NICE

With regards to ‘Medically Unexplained Symptoms (MUS) not otherwise specificied’ the recommended specialised form of CBT is entirely a product the IAPT Education and Training Group (ETG). The ETG is also a reference source for the specialised form of CBT for irritable bowel syndrome and chronic pain, albeit that 2 NICE guidelines are also referred to.

Myth Seven: IAPT is becoming more robust in evaluation

Not according to its’ recent forays into disorders like chronic fatigue syndrome were reliance is placed on a psychometric test the Chalder Fatigue scale of doubtful relevance to the CFS construct and without any independent observer rating.

Myth Eight: Real world change can happen without hospitality and commitment

Hospitality is notably absent in client’s first contact with IAPT , therapists are focussed on not becoming the subject of sanction. In the real world initial formulation of client’s problem/s is often in need of significant modification, the time constraints on therapists rarely cater for the necessary adaptations and the importance of persistence on the part of the therapist.

Myth Nine: It is ok to discharge a client as soon as their score hits recovery

For 40% of people experiencing depression, their disorder takes a variable course, whilst for the anxiety disorders, sufferers are only affected 80% of the time. Thus discharging at the first signs of a low score is simply capitalising on chance, there can be no certainty that lasting meaningful change has occurred. The stage is set for a revolving door.

This list of myths is by no means exhaustive, please feel free to add your own. However the microscopic and macroscopic worlds are different universes it seems.

Dr Mike Scott

and the added value of low intensity IAPT is?

compared to how people would have got on anyway if not referred to IAPT (in economist terms the appropriate counterfactual), the ‘added value’ has not been demonstrated. Yet most people receive a low intensity intervention such as computerised CBT, guided self help or groupwork.

I could find no independent outcome assessors involved in the randomised controlled trials of low intensity interventions that the NICE guidance largely relies on. Instead reliance has been placed on IAPT’s marking and marketing of its’ own homework.

In a review of randomised controlled trials published in 4 medical journals Kahan, Rehal and Cro (2015) only a quarter (26%) involved blinded outcome assessment. These authors write ‘Previous reviews have found that unblinded outcome assessment can lead to estimates of treatment
effect that are exaggerated between 27% and 68%’ see link below:

https://www.dropbox.com/s/aarqu8j95udwmpl/Blinding%20independent%20assessment%20rare%20%202015.pdf?dl=0

But the position appears worse when it comes to psychological therapies with no reliable rcts for low intensity interventions, and with regards to high intensity interventions the few blind outcome assesments are clustered around depression, the anxiety disorders and PTSD. Since the millenium there has been a drift away from the use of outcome assessors, this makes research cheaper, it is much easier to massage statistics to give a positive hue, the originators of an intervention and those with a vested interest are given a free hand.

Researchers on IAPT [seee Bower et al (2013)] play fast and loose with Cochrane risk of bias tool, see link below:

https://www.dropbox.com/s/bmr98o8z8fcfuzv/paths%20to%20mh%20Cochrane%20Risk%20of%20bias%20assessment%20tool.pdf?dl=0

and jettison the need for independent blind assessment implicit in the tool on the spurious grounds that ‘most outcomes are self-reported’ see link below:

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

Looked at from the perspective of independent outcome assessment the claims for low intensity interventions look spurious and the evidence base for high intensity interventions is more circumscribed than BABCP conferences or IAPT would suggest.

The IAPT Manual published last year recommends extension of the service to irritable bowel syndrome, chronic fatigue syndrome, chronic pain and medically unexplained symptoms not otherwise specified but makes no mention at all of the need for independent blind assessment of outcome, instead it suggests simply what self-report measures should be administered. See link below:

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

Yet another marketing opportunity, when we need real world answers, how many people said to an impartial observer that they were back to their usual selves after the intervention? how long did this last?

Dr Mike Scott

Sham Psychological Therapy Rules

Bernard felt ‘ten times worse’ after his first session of IAPT, Group CBT. He didn’t return for further sessions. IAPT advised him to seek individual therapy via his GP, which he did but none was ever forthcoming. When I saw him it was three years after his industrial accident that rendered him unable to work, his depression had continued unabated. The GP records simply recorded that he did not attend 3 sessions and so was discharged, the implication was that he was at fault!

What had actually happened is that following an IAPT telephone assessment he was invited to therapy at a local centre. On arrival he and others were given a questionnaire to complete. He and about 15 others were then ushered into a room, but there were not enough chairs so some stood. The group leader began asking each of them in turn what their problem was. Bernard protested ‘ I can’t tell my problems in front of all these’, he said that he could see that the young men in the group were agitated and one ‘girl’ on the verge of tears. ‘it was more like a lecture with flipchart and screen’.

The IAPT treatment bears no relationship at all to the group CBT detailed, in my book ‘Simply Effective Group CBT’ published a decade ago by London: Routledge or to what I am trying to promote as Co-chair of the BABCP Group CBT Special Interest Group. A year ago the IAPT Manual was published but none of it confers any protection for a client suffering the same fate. The worry is that in the interest of a numbers game more people will suffer Bernard’s fate.How long is the cover up going to go on!

Dr Mike Scott

IAPT Hoodwinks NHS England

by alleging compliance with NICE recommended evidence-based psychological treatments. But, NICE bases its’ recommendations, largely, on randomised controlled trials conducted on specific disorders, with different protocols for different disorders. It is impossible to implement NICE guidance without reliable diagnosis, but IAPT have never claimed that its’ clinicians make a diagnosis!

Even the notion of a utilising a ‘provisional diagnosis’ was jettisoned in last years IAPT Manual, (see link below) in favour of a ‘problem descriptor’:

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

On the basis of a client’s ‘problem descriptor’ the IAPT Manual requires its’ therapists to specify an ICD-10 [International Classification of Diseases 10th edition, World Health Organisation] code for a disorder, which would allegedly indicate the appropriate protocol. However there are 99 codes for Mental and Behavioural Disorders in ICD-10, there is no bridge between a ‘problem descriptor’ and a disorder. If such a leap were possible ICD-10 ( the World Health Organisation) would not have bothered to specify diagnostic criteria for the 99 conditions! Within IAPT clinicians come up with a ‘problem descriptor’ in just 2/3rds of cases, [ Clark et al (2018)] see link below:

https://www.dropbox.com/s/s7var6llzwt1otd/IAPT%20and%20Transparency%20Clark%202018.pdf?dl=0

and usually following a 20-30 minute telephone conversation, it is therefore a matter of ‘plucking a code’ from thin air for administrative purposes,


if the clinician can remember this particular ticking the box exercise.

The Clark et al (2018) study was published in the Lancet, and funded by the Wellcome Trust, and headed ‘Transparency about the outcomes of mental health services (IAPT approach): an analysis of public data’ and states:

‘Role of the funding source
The funder of the study had no role in study design, data
collection, data analysis, data interpretation, or writing of
the report. The corresponding author had full access to
all the data in the study and had final responsibility for
the decision to submit for publication’.

But there is no mention that the lead author is the leading light in IAPT, and that with one of the other authors, Lord Layard, they were the architects of IAPT. Where is the ‘transparency’ in this? In fairness in this paper they do state that a limitation of their paper is that their data is dependent entirely on client self report, but a conflict of interest stops them going on to say, that there needs to be an independent audit of IAPT, in which the diagnostic status of clients is assessed before and after treatment and at follow up.

My own independent analysis of 90 IAPT clients suggests that, contrary to IAPTs claims of a 50% recovery, just the tip of the iceberg loose their diagnostic status diagnostic status, see link below: https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

NHS England needs to clearly establish whether or not the public is ill served by IAPT and not to rely on the claims of those with a vested interest in providing the Service.

Dr Mike Scott