‘Psychometric Testing In Clinical Settings’ – contains a devastating critique of IAPT

this is the title of a Chapter, by Hamilton Fairfax in a book ‘Psychometric Testing’ edited by Barry Cripps in (2017) and published by John Wiley. Fairfax pulls no punches, on the over interpretation of a psychometric test score:

‘These concerns are increased when organisations place value on such scores, and base commissioning and service decisions on them away from the clinical context. Increasingly, such decisions by NHS and private health care providers are made by individuals who are either not familiar with the specifications of services or not sufficiently trained clinically or methodologically to understand the information they are provided with. Instead they are under pressure to ensure services are economically viable; the attraction of a number that purports to measure improvement is obvious. It is possible to manage mental health services in a way that would not be permissible in banking, the military or food production.

One risks accusations of arrogance or pomposity if one’s critique of a management decision is based on the manager’s lack of awareness or training. A strange and unintended consequence of EBP (evidence based practice) is that it provides a heuristic for the uninformed to speak with authority in a way in which many of us would not speak to a mechanic just because we had read a car manual. Stating that something is ‘evidence-based’, whether or not the person knows much about the area being discussed, is often seen as sufficient. It is dangerous to base policy and the survival of clinical services on this level of insight. In outlining this position I do not want to demonise managers or create an equally unhelpful heuristics. Many are well informed, with good clinical experience, but their roles have increasingly alienated them from the realities of practice. Demand and the pressure to be more effective can diminish flexibility and creative thinking, leading to a reliance on quick information such as numbers and ‘evidence’. I speak from personal experience and am aware that these pressures only increase with more responsibilities’.

Hopefully we can manage a better New Year

Dr Mike Scott

Questions NHS England and IAPT Have Ignored Over Covid

 

How do you distinguish an adaptive reaction to Covid from a maladaptive one? Without answering this fundamental question NHS England has offered guidance….https://www.yourcovidrecovery.nhs.uk/managing-the-effects/effects-on-your-mind/managing-fear-and-anxiety/. on how psychological debility associated with having Covid might be managed. They offer a range of cognitive behavioural strategies commonly employed in the management of anxiety and depression. In addition they invite the public to complete a quiz, https://www.nhs.uk/conditions/stress-anxiety-depression/mood-self-assessment/ that actually comprises the questions in the PHQ-9 (that measures the severity of depression) and the GAD-7 (that measures the severity of generalised anxiety disorder), together with a question on the extent to which they feel impaired by these difficulties.

If the person scores highly on the quiz they are advised to see their GP and/or refer themselves to IAPT, as a diagnosis can only be made by professionals. But the IAPT Manual states IAPT therapists don’t make diagnosis, further they have no expertise with regards to a physical disorder.What then would an IAPT therapist be treating?

How meaningfully can a GP determine whether the fatigue associated with Covid should count towards a diagnosis of depression? Should the low mood associated with being ill count as a depressive symptom? Many Covid patients have breathing difficulties that can disturb sleep, should this insomnia count as a depression symptom? Loss of appetite is a common symptom of being ill, should it count as a symptom of depression? Should the worries of a Covid patient about the trajectory of their illness and occupational/financial impairment count as a symptom of anxiety?  With the exception of helping patients with Covid who are suicidal, psychologising Covid patients symptoms looks like an exercise in empire building.  

Whilst NHS England’s offering of the CBT strategies to members of the public might not be unreasonable, there is no evidence that these strategies taken out of the context in which they were developed make a real-world difference to those with a long term condition. Equally there is no evidence that such strategies delivered by IAPT practitoners makes a real world difference, the service has a recovery rate of 10% Scott (2018) https://doi.org/10.1177/1359105318755264

Are we to assume that those most debilitated by Covid, the likely most stressed, are the most in need of psychological intervention?

What body of knowledge do psychological therapists have that would make a real-world difference to the outcome of Covid in a particular instance?

 

Dr Mike Scott

Following NICE Guidance On Covid Treatment Threatens To Overwhelm Mental Health Services

Yesterday NICE issued guidance on the management of Covid post 12 weeks (long term) https://www.nice.org.uk/guidance/ng188 and recommends that those with mild anxiety or mild depression are referred to mental health services, with severe cases of anxiety/depression referred to psychiatrists. IAPT (Improving Access to Psychological Therapies) has already been conducting webinars for its’ Step 3 staff, within which concerns were expressed about possibly overwhelming services and the pathologising of normality. Despite this further webinars are planned for the low intensity (Step 2) staff. Buoyed by its’ success in attracting monies for psychological therapies for long-term conditions (LTCs), such as chronic pain, irritable bowel syndrome, IAPT sees an opportunity to extend its’ reach to those affected by Covid. Those with long term Covid are likely to suffer the same fate of those with Chronic Fatigue Syndrome of not being really listened to. 

Given that according to NICE the most common features of long term Covid are fatigue, ‘brain fog’ and breathlessness, and that ‘symptoms of anxiety and depression’  are presented as possible symptoms of Covid at any stage, how is it possible to make an additional diagnosis of anxiety and depression? With the exception of the few, Covid patients who may be suicidal the distinction between the physical and psychological symptoms is fraught with difficulties. One response is to ignore the distinction, ignore the science and claim that all with Covid need a psychological therapist, but there is no scientific evidence for this – albeit that it suits the purposes of service providers to make such a claim. If you were not feeling ‘mildly anxious or depressed’ when you contract Covid that is probably very worrying!

An editorial in the British Medical Journal http://dx.doi.org/10.1136/bmj.m4425 bemoans the medico-political contexts that has hampered scientists expressing their concerns over the evidence base for handling Covid. But such a medico-political context has operated for years with regard to IAPT. There has been no independent evidence that IAPT’s work with sufferer’s from LTC’s has led to the resolution of accompanying psychological disorders. There has been no comparison with an active placebo or with the fate of LTC sufferers before the advent of IAPT.  The National Audit Office was allowed to suspend its’ investigation of IAPT in 2017, with no check on the appropriateness of having spent £4 billion of the public purse on the Service. Matters have been compounded by the BABCP’s (the lead organisation for cbt) unwavering support for IAPT and the British Psychological Society’s endorsement of IAPT training. Despite any evidence that the competence of therapists trained relates to client outcome Liness et al (2019) https://www.dropbox.com/s/e26n191ie09sngs/Competence%20and%20Outcome%20IAPT%20no%20relation%202019.pdf?dl=0.

2021 can only get better, one needs hope, I think that this is the message of Christmas.

Dr Mike Scott

IAPT’s Black Hole – Accountability

I recently asked the National Audit Office to restart it’s investigation into IAPT. I am expecting their reply in the next week or two. There has been no independent scrutiny of IAPT. They have been answerable only to Clinical Commissioning Groups, which have consisted largely of GPs and allowed IAPT to mark its’ own homework.

But the accountability gap also extends downwards, where is the evidence that front line staff or clients have been consulted or involved in decision making?  Most recently IAPT has offered webinars, for its staff on helping those with long term COVID.   There is a tacit assumption that this will be within the expertise of IAPT therapists just as helping those with long term physical conditions such as irritable bowel syndrome. But the IAPT staff working with LTCs were never consulted, before this new foray. Client’s with LTCs were never asked whether they were back to their old selves (or best functioning) before this proposed further extension of IAPT’s empire.  

In the forthcoming issue of the British Journal of Clinical Psychology I have challenged IAPT’s account of its ‘performance’ see ‘Ensuring IAPT Does What It Says On The Tin’ https://doi.org/10.1111/bjc.12264. There is a reply in rebuttal see ‘The costs and benefits of practice-based evidence: correcting some misunderstandings about the 10-year meta-analysis of IAPT studies’ https://doi.org/10.1111/bjc.12268 that reveals a breathtaking level of conflict of interests. IAPT and its’ fellow travellers should be held to account. But importantly they also need to account to their therapists and clients. [ The original IAPT paper is available at https://doi.org/10.1111/bjc.12259]

 

Dr Mike Scott

IAPT, No Better Than Placebo?

There is no compelling evidence that the Improving Access to Psychological Therapies (IAPT) service is any better than a placebo, yet its’ expansion continues to be funded, despite £4 billion having already having been spent on it. Barkham and Saxon (2018) https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-018-1899-0  in their study of IAPT, found a within subjects  overall effect size of 0.93, amongst clients attending a mean of 6-9 treatment sessions. [Effect size is calculated by subtracting the mean post-treatment score from the mean pre-treatment score and dividing by the pooled pretreatment standard deviation]. But Huneke et al (2020) https://doi.org/10.1017/ S0033291720003633 cite placebo effect sizes of between 0.65 to 1.29 in anxiety disorder outcome studies. This raises serious doubts on the added value of IAPT.  They further note that approximately 30% of patients in antidepressant and antipsychotic trials respond to placebo treatment. Whilst Barkham and Saxon indicate that 50% of IAPT clients make a reliable and clinically significant improvement, adjusting this figure for differences in the severity of mental illness, likely produces a response rate not obviously different to that in IAPT. 

However the above considerations are not definitive, IAPT’s performance has never been compared with an active control condition, leaving the jury out on its’ performance. Unfortunately this has left IAPT free to drain the public purse at will. The ultimate disgrace is that the Government/Public Health England have not subjected IAPT to independent scrutiny. Such a position would not be tolerated with regards to a vaccine, but it is apparently ok to look the other way on mental health.

Dr Mike Scott