Month: October 2020

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Psychological Wellbeing Practitioners (PWPs) Ill-equipped, Yet On Sentry Duty

John, a client of mine,  had a telephone assessment by a PWP at the IAPT (Improving Access to Psychological Therapies) Service and was told that he might have bipolar disorder. IAPT referred him to Secondary care but without any indication of how long he would have to wait for an appointment, nor any indication of the possible consequences. Within minutes of talking to him it was apparent that he had never had an elevation of mood that lasted more than a day. Albeit, that on his best days he felt he could do anything, but others had never reported that his behaviour was strange or bizarre at those times. John did get low but not most of the day, most days.

The PWP hadn’t picked up at all that he was troubled by obsessive thoughts of engaging in embarrassing behaviour. John in fact had OCD but without overt ritualistic behaviour. It takes little imagination to realise that a client is likely to Google any suggestion that comes from clinician, making it wholly unacceptable to hint at severe mental illness without due care and attention. PWPs are simply not equipped for the purpose of guarding entry into the mental health services. Nor is there any credible evidence that they deliver evidence based treatment. 

Consider how PWPs operate, armed with the results of a PHQ9, they interpret a score of 10 or more as indicative of depression. As a result it is quite likely they will be placed on what they consider a suitable trajectory for a depressed client. But Zimmerman (2019) [Using the 9-item Patient Health Questionnaire to Screen for and Monitor Depression, JAMA, 322, 2125-2126] has pointed out that the instrument over diagnoses people as being in the severe depression category and misses people in the mild category. He cautions that the instrument is not diagnostic and should only be used in the context of a standardised semi-structured interview such as the SCID, measuring change. Both BABCP and the British Psychological Society have been enthusiastic backers of IAPT, but have taken no steps to ensure that PWPs are aware of the limitations of self-report measures. They bear the responsibility for the current mess – for their own reasons they have put dissemination of services ahead of everything else.

A study by Chris Williams (2018) Williams, C., McClay, C., Matthews, L., McConnachie, A., Haig, C., Walker, A., & Morrison, J. (2018). Community-based group guided self-help intervention for low mood and stress: Randomised controlled trial. The British Journal of Psychiatry, 212(2), 88-95. doi:10.1192/bjp.2017.1 shows the bizarre conclusions that can flow from reliance on the PHQ9. He and his colleagues recruited patients from the community with possible depression, with a mean PHQ9 score of 15.2 (and standard deviation of 5.4) thus over 80% (83.8%) of cases would have been regarded as depressed.  But according to the MINI diagnostic interview none of those in the immediate treatment group met criteria for depression and only 4% of those in the delayed access had depression. Despite the colossal mismatch between the PHQ9 results and the MINI  he and his colleagues concluded that ‘low intensity class based CBT delivered within a community setting is effective for reducing depression, anxiety and impaired social function’ .  This highlights the weak to non-existent evidential base for low intensity cbt.

 

Dr Mike Scott

 

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IAPT’s Below Intensity CBT – Rhetoric vs Reality

 

The Improving Access to Psychological Therapies (IAPT) Service clients receive on average 6 sessions (amongst those who complete 2 or more sessions), compared to the typical 13  sessions in the 29 evidence based, ‘gold standard’, randomised controlled trials, considered by OST (2008) doi:10.1016/j.brat.2007.12.005. The discrepancy in the dosage of treatment creates a suspicion that, in routine practice, clients receive a sub-therapeutic dose of treatment.

In practice the Service haemorrhages clients, with 60% of all referrals not completing treatment in 2017-2018,  Moller et al (2019) https://doi.org/10.1186/s12888-019-2235-z.  In this period a third (35%) of clients were given an unspecified diagnosis making the delivery of a NICE approved evidence based treatment impossible. The IAPT services claim to a 50% recovery rate, comparable to that in randomised controlled trials, is preposterous in this context.

Service providers, such as IAPT, are necessarily opportunistic and overstate the power of a simple and cheap mode of service delivery, thereby doing wonders for their power and bank balance. But clients are the losers, particularly those from disadvantaged backgrounds, Moller et al (2019) https://doi.org/10.1186/s12888-019-2235-z.

The rhetoric was that the Service would pay for itself because of the positive effects on employment but Moller et al (2019) have found no evidence of this https://doi.org/10.1186/s12888-019-2235-z.Employed: Start of treatment 316,604; end of treatment, 302,746; Unemployed and seeking work: Start of Treatment, 54,580; End of Treatment 49,803; Long term sick or disabled or in receipt of benefits; Start of Treatment, 43,275; End of Treatment, 43,671. Using IAPT’s own data for 2017-2018,  there is a 17% difference in recovery rate depending on whether the client was from the most deprived area , with a 41.0% recovery rate compared to a 58.1% recovery rate for the least deprived area.

 

Dr Mike Scott

 

 

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The Mistreatment of IAPT Clients – The Smoking Gun

What right has the Improving Access to Psychological Therapies (IAPT) Service to routinely label each client with a diagnostic code (ICD of the International Classification of Disorders, World Health Organisation) when the Organisation’s Manual states that it does not do diagnosis. Fearful of litigation, it states that its diagnoses should not be used for medico-legal purposes, but as the code is the determinant of treatment, IAPT should be in the dock!

The Improving Access to Psychological Therapies (IAPT) service screens clients for treatment using the PHQ-9 but a study published in the British Medical Journal by Brooke Levis et al last year http://dx.doi.org/10.1136/bmj.l1476  indicates that half the  deemed depression cases  have been incorrectly diagnosed. 

In high quality randomised controlled trials of the treatment for depression all clients admitted have been diagnosed as having depression according to a ‘gold standard’ diagnostic interview such as the SCID. The recovery rate in the rcts is 50%. But IAPT claims that it approaches the recovery rate of rcts. This is preposterous! Consider 100 IAPT cases which score above the PHQ-9 cut off of greater or equal to 10. One half of them i.e 50 will not actually have depression and therefore cannot recover from the disorder. Of the other half, 50 cases, if the IAPT clinicians were as good as in the rcts 25 would recover. Thus the maximum possible recovery rate for depression in IAPT is 25% and this is assuming its clinicians are as good as the highly trained clinicians in rcts. More plausibly the recovery rate for depression in IAPT is the 14.9% I found in my independent study of IAPT, http://DOI: 10.1177/1359105318755264 https://doi.org/10.1177/135910531875 using the SCID.

In primary care 22% of patients score over 10 on the PHQ9, so what are the treatment implications for the likely 3 out of 4 IAPT clients who score below 10? For these the PHQ-9 offers no direction.

But IAPT has its’ own answer, IAPT Manual, p 24  (2019), a) come up with a problem descriptor then choose an ICD 10 that that ‘matches’ the descriptor and  then b) a NICE treatment that matches the ICD 10 code.  Consider an IAPT client who reports that they are feeling emotionally numb at work, detached from others and fatigued after little exercise. The therapist could plump for either depression, burnout, chronic fatigue syndrome or the effects of COVID-19, with no guidance as the appropriate label! 

Using IAPT system Delgadillo et al (2020) http://dx.doi.org/10.1037/ccp0000507 classified over 40% of clients as having ‘Affective Disorder’  and over 20%  as having a ‘mixed disorder’. But there are no randomised controlled trials for ‘affective disorder’ or ‘mixed’, so that for 60% of IAPT’s clients there cannot be an appeal to an evidence based treatment (i.e one based on a randomised controlled trial). Considering again a sample of 100 IAPT clients who score less than 10 on the PHQ9 60 of them will have been labelled with a disorder for which there can be no evidence based treatment, this leaves 40 clients who in principle could be treated  with an evidence based treatment. Again assuming that for this population of 40 that allegedly covered GAD (10-12%), panic disorder (4-6%), social anxiety disorder (4-6%), specific phobia (0.5-1.0%), OCD (4-5%), PTSD (6-8%) and other (2-3%) there was an overall recovery rate of 50% only 20% of the allegedly ‘non-depressed’ clients would recover. This 20% would have to regarded as an upper limit because it assumes the IAPT therapist would be as skilled as the highly trained therapists involved in the rcts for anxiety disorders. A more realistic estimate of recovery for the IAPT ‘anxious clients’ would be the 14.2% found in my study of IAPT clients http://DOI: 10.1177/1359105318755264 https://doi.org/10.1177/135910531875

The other metric employed  by IAPT is the GAD-7, a measure of the severity of anxiety, but as according to IAPT it has only been relevant to one in 10 of its service users, any effect of the treatment of this disorder will only effect the above picture minimally. Assuming a 50% recovery the effect will be even less and less still when one compares the training of therapists in GAD acts with the training of the routine IAPT therapist.

IAPTS sole reliance on psychometric tests and fudge has backfired badly, but it is the client who suffers most, with therapists suffering from the recoil.  

Dr Mike Scott

 

 

 

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Number Theatre and Routine Mental Health

the National Institute for Health Research has just published a review of studies of the psychological treatment of Medically Unexplained Symptoms (MUS) https://doi.org/10.3310/hta24460 [Leaviss J, Davis S, Ren S, Hamilton J, Scope A, Booth A, et al. Behavioural modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation. Health Technol Assess 2020;24(46)] but in all studies the primary outcome measure was an improvement of symptoms on some psychometric test. No categorical measure was used such as no longer suffering from a ‘disorder’ such as fibromyalgia, irritable bowel syndrome or chronic fatigue syndrome post treatment. Likewise the Improving Access to Psychological Treatment (IAPT) markets its success on a change in score on psychometric tests the PHQ-9 and GAD-7. Further whether or not an IAPT clinician is to be subjected to a formal review of competence is based on a change of score on these measures. No categorical measure is used such as the proportion of cases of depression, panic disorder, generalised anxiety disorder etc that have lost their diagnostic status. Sir David Spiegelhalter the Statistician has coined the term ‘number theatre’ to describe the way in which the UK Government has promulgated statistics in relation to the Pandemic, but this drama been playing for years in the mental health arena.  I am reminded of a line from a song somewhere, ‘I am more than a number in a little red book’, although intended for a very different context, it seems particularly apt for IAPT.

Lies
Damned Lies
and
IAPT
 

Number theatre in the mental health field has it seems been driven by the desire of psychologists to colonise. It is a reaction against the categorical labels employed by psychiatry. But the truth of the matter is both are needed simultaneously. To take a medical example, if I have a heart problem I need to know what the problem is but also my blood pressure today.

IAPT will topple because it pivots on psychometric tests. Inspection of of its’ main pillar, the PHQ-9 exposes a crumbling structure:

  1. Client’s judgement of their functioning does not match changes on the PHQ-9 https://doi.org/10.3310/hta24460. Thus an IAPT therapist might report to his supervisor the ‘improvement’ on his/her clients score on the PHQ-9 and at the same time report that the latter said they are ‘the same old’. The overall judgement of the client is likely to be dismissed in favour of the alleged ‘moving towards recovery’ or ‘recovery’ on the PHQ-9.
  2. In the initial validation study of the PHQ-9  by Kroenke and Spitzer it was not validated against a ‘gold standard’ that it was sufficiently different to to make it an acceptable diagnostic aid according to the AMSTAR
  3. The findings of the progenitors of the PHQ-9 Kroenke and Spitzer were not replicated by independent researchers using a ‘gold standard’ diagnostic interview  such as the SCID.
  4. The diagnostic accuracy of an instrument depends very much on the prevalence of the disorder in which it was first evaluated. In the case of the PHQ-9 psychiatric outpatients in the United States. There is no reliable evidence (as assessed by a standardised diagnostic interview)  on the prevalence of disorders amongst those attending IAPT (which include both self referrers and GP referrals).  Thus the clinical utility of the PHQ-9 in this context is unknown.
  5. The PHQ-9 is purportedly a measure of the severity of depression, but there is poor concordance between it and alternative measures of the severity such as the HAD i.e a person would be in a different category of severity depending on which measure is used.

5. The use of a psychometric test with a summary score assumes that each of the items (9 in the case of the PHQ-9) contribute equally to the total score. But this is implausible an item about suicidal ideation (item  9 on the PHQ-9) is likely to  be more significant than an item about fatigue. 

6. Two patients on the PHQ-9 could have the same score, but arising from one patient endorsing all intermediate scores whilst the second endorses several items at the highest score. The same score but arguably a quite different meaning.

7. The PHQ-9 assumes that is the frequency of a symptom  that is the determinant of severity rather than the intensity. 

8. Unless the mechanism by which a PHQ9 score is changed is known it cannot determined that an evidence based treatment was in fact used. Thus those getting a supposed ‘result’ may be more at fault than those acknowledging none response, the latter may simply be more honest. 

These considerations on the PHQ-9 may not be prohibitive of its use, if employed in the context of a standardised diagnostic interview that has established the person has depression. But such an interview would likely also yield the presence of one or more coexisting disorders. The trajectory of these additional disorders would have to be tracked by other psychometric tests that are pertinent to the disorder. The idea that the  PHQ-9 can stand alone as judge and jury on a client’s mental health is absurd.

However politicians, public health bodies and clinical commissioning groups like to be told that there is a simple solution to a problem and that they can make a difference by implementing the chosen solution. Enter stage right IAPT proclaiming ‘give the PHQ9 reduce it below 10, job done and woe betide any clinician who does not manage this routinely’. As an encore IAPT uses numbers e.g throughput of clients, waiting lists to placate politicians and funders.  Exhaustion, numbing and detachment [burnout] are an inevitable consequence of these working conditions. No amount of self-reflection as advocated by Psychological Wellbeing Practitioner in the current issue of CBT Today, is going to make a real world difference. It is a shame that CBT Today has become IAPT’s comic.

Dr Mike Scott