Month: January 2020

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Audit of Secondary Care Psychological Therapies Fails Clients

The National Clinical Audit of Anxiety and Depression (NCAAD) has just been published https://www.rcpsych.ac.uk/members/your-monthly-enewsletter/january-2020-enewsletter/anxiety-and-depression-report?dm_i=3S89,13323,2H3J22,3SCFB,1 but it is impossible to gauge from it what proportion of those with anxiety or depression recovered with psychological treatment. There was no reliable methodology employed to determine what constituted a ‘case’ of anxiety or depression and there was no independent evaluation of outcome. 

No evidence is provided that psychological therapy made a real world difference to client’s lives.  The authors reported that 75% of service users agreed that their therapy helped them to cope with their difficulties, with 88% agreeing they were treated with empathy, dignity and kindness.  The average number of treatment sessions attended was 13. Having made such a time investment clients  are unlikely to be critical of the service they received particularly, as was usually the case, the therapist was judged a nice person. 

The report opines that 65% of service users were receiving a type of therapy in line with NICE Guidance for their disorder. But given that diagnostic status was not reliably determined there can be no certainty that an appropriate NICE protocol was used. There is nothing in the report to indicate that treatment records were reviewed (or capable of review) in such a way as to determine matching treatment targets, strategies and disorder. This makes one sceptical of the authors claim that the main intervention was CBT, it is alleged CBT. With just over a half completing the planned number of sessions. With a further 1 in 3 people receiving a type of treatment that was not NICE compliant even by the standards of the authors of the report.  

The authors call for an increased use of psychometric tests (no test was used in more than 15% of cases) and a reduction of waiting times (almost half waited over 18 weeks). Doubtless these are laudable aims but of themselves are unlikely to make any real world difference to client’s lives.

There is a legitimation of current practice, with implicit claims for more funding and better training, all horribly reminiscent of the failed IAPT service.  The National Audit Office needs to not only re-ignite its’ inquiry into IAPT but also determine whether secondary care psychological therapy is value for money – the NCAAD provides no evidence of the latter.

Dr Mike Scott

 

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NHS Improvement Reveals Hole in IAPT’s Bucket

but the NHS has taken no steps to stop the haemorrhaging of clients and money.  A quarter (25.3%) of IAPT’s expenditure in 2017-2018, £75.58 million, was devoted to clients who were either not assessed or were not put in any care cluster (groups of diagnoses), according to the National Schedule of Reference costs see link https://www.dropbox.com/s/3xlu6tipaeguk2c/FOI%20IAPT%20data.xlsx?dl=0

which I acquired through a Freedom of Information Request. Curiously only 15.2% of IAPT’s expenditure, £45.68 million in 2017-2018 went on common mental health problems of low severity, whilst £176.86 million (58.99%) was spent on non-psychotic disorder.

For those with common mental health problems of low severity there were 214,863 high intensity contacts compared to 378,617 low intensity contacts. Thus low severity often appears to necessitate high intensity contacts, this raises questions about the reliability of ‘common mental mental health problems of low severity’ category.

For non-psychotic disorders 1.075 million high intensity contacts were delivered and almost as many low intensity contacts, 0.876 million. Assuming that the those categorised as a having a non psychotic disorder are more functionally impaired than those with common mental health problems of low severity, why are they having so many low intensity contacts? Sticking plasters for serious injury! It is time for the National Audit Office to restart its’ inquiry. 

 

Dr Mike Scott

 

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Unregulated Mental Health Service Has Run Away With £4 billion

Following a Freedom of Information request NHS Improvement confirmed to me yesterday that the the total cost of the Governments Improving Access to Psychological Therapies (IAPT) Service in 2017/18 was £394 million.  I had asked them for the annual cost of IAPT since its’ inception, but they said that they were unable to furnish such figures! The service is twelve years old, thus conservatively it has likely cost the taxpayer £4 billion. 

For Rail and Road we have a regulatory body the  Office of Rail and Road, that monitors the performance of Network Rail and the varying train operators, but for mental health there is no such independent regulatory body. IAPT polices itself, and makes unexamined claims of recovery rates to secure funding from Clinical Commissioning Groups, who have never performed an independent audit. In my own area, Talk Liverpool last October publicly claimed an 87% recovery rate  for those who completed treatment, unsurprisingly therefore the Liverpool CCG has increased its funding by 25% to 10 million in the coming financial year. My own research published in 2018 suggests an actual 10% recovery rate.

It is time that the Government and Dominic Cummings got to grips with this.

The dropbox link to the FOI  response is below:

https://www.dropbox.com/s/x5kza6e6bpft2b3/Scott%20Internal%20Review%20Decision%20Letter%2020.01.2020.pdf?dl=0

My own findings are in the dropbox link below;

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

more about these matters anon

Dr Mike Scott

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A Critical Transatlantic Take on IAPT

Dr David Tuller from the University of Berkeley, California has penned a very critical blog on IAPT  http://www.virology.ws/2020/01/15/trial-by-error-cbt-provides-no-benefits-to-advanced-cancer-patients-study-finds/

two years ago he was one of the authors of a reanalysis of the PACE trial data on the efficacy of CBT for chronic fatigue syndrome and essentially found the data had been fudged.

Dr Mike Scott

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Rely Solely On A Self-Report Measure To Hike Up Funding and Fudge Outcomes

the routine audit of mental health services such as IAPT, is based on client self-report measures such as the PHQ9.  This carries the implicit assumption that the cut offs by themselves meaningfully distinguish cases from non-cases.   Correspondence in this months British Journal of Psychiatry highlights how misleading reliance on a single self-report measure can be. One study using this methodology claimed two fifths of 11-15 year olds had mental health problems  but when in another study assessment was conducted using standardised diagnostic interviews and diagnostic criteria the figure was just 13.6%!. doi:10.1192/bjp.2019.225

Whilst claims of high prevalence rates might be good for funding purposes and placing mental health on the public agenda there is no real world change for clients, the powerholders are the only beneficiaries.

In October 2019 my local IAPT claimed 87% (Talk Liverpool Performance Data) of those who completed treatment recovered in the previous 12 months, making Talk Liverpool outperform all other IAPT services (a national claim of a 50% recovery)! I can only think that Talk Liverpool have looked with envy at how Liverpool FC outperforms  all other teams and has gone into delusional mode! My own    study of 90 IAPT clients that I assessed independently using a standardised diagnostic interview showed that only the tip of the iceberg recover, see link below:

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

Rogers and Bender have written about ‘the myth of the laser accuracy of cut offs’ in their seminal work ‘The Clinical Assessment of Malingering and Deception’ (2018) Guilford Press.  Clinical Commissioning Groups could do with lessons in all these issues when interacting with IAPT and stop displaying such breathtaking naivety. 

Dr Mike Scott

 

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Groups An Attractive Option…. But?

Last month I gave a days workshop ‘Better Together’ at the Maudsley Hospital for an IAPT Service, I did think it was going into the lion’s den but the hospitality was superb.  The link to my presentation is below:

https://www.dropbox.com/s/4i2tw7l2t4rxnfr/Better%20Together.pptx?dl=0

I presented  for the  first time the DAGger for groups, a questionnaire containing the dysfuntional attitudes that will often have to  be circumnavigated to successfully engage someone in a group. I also spelt out how to engage in a debate about the ‘DAG’s using the vectors of validity, utility and authority. But such dialogues are not easily possible with IAPT’s standard triage, there is a need  for reform to make groups properly viable. One of the problems with groups is that those most likely to benefit from groups are those least likely to agree to attend!

Groups are not the same as classes and I was struck at the Workshop by the lack of understanding that there is a strong evidence base for the former       for depression and most  anxiety disorders but the evidence base for the latter is extremely weak by comparison. There was also near universal acceptance that a stepped care model was intrinsically better and that not having an extended face to face conversation with a client initially was in any way problematic. Near the end I did mention my  findings of a 10% recovery rate in IAPT see link below:

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

but by then attendees were either too tired/polite/fearful to say anything. But I must thank Marion Cuddy the organiser for a great day.

Dr Mike Scott