Government Gives £38 million Extra To A Mental Health Service That Has Already Crashed With Real Life Clients

the typical client presenting at the Improving Access to Psychological Therapies (IAPT) service, 58%, are suffering from three or more disorders , with 14% suffering from two disorders [Hepgul et al 2016 https://doi.org/10.1186/s12888-016-0736-6]. The interventions delivered by IAPT are most commonly minimalist, little contact with a therapist other than to supervise the client’s use of computerised CBT. Strategies on offer in IAPTs low intensity intervention can be found in any CBT self-help book. It can reasonably anticipated that its’ treatments are destined for failure. 

The complexity of IAPT’s target population is highlighted further by a) the study of Zimmerman et al (2005) https://doi.org/10.1176/appi.ajp.162.10.1911 which suggests that a third of IAPT clients likely have a personality disorder b) Hepgul et al’s (2016) finding that 21% reported moderate or severe sexual abuse and 16% moderate or severe physical abuse and c) Hepgul et al’s (2016) finding that 18% had alcohol dependence and 7% substance dependence. The IAPT manual (2019) claims  that its’ therapists provide treatment according National Institute for Health and Care Excellence (NICE) guidelines, but the latter recommend treatments for single disorders.  Further IAPT provides no evidence of fidelity to any particular protocol. The NICE recommended treatments are based on randomised controlled trials (rcts) of CBT for single depression and anxiety disorders with limited concessions to  comorbidity, not for the range of complexity encountered in routine practice. Thus whilst it is the the case that on average 50% of those in the rcts for depression and the anxiety disorders are in remission at the end of treatment, it is most unlikely that this could be achieved with the IAPT population, yet the service claims exactly this success rate!  

New IAPT staff are like army recruits in the 1st World War, full of optimism, ill prepared for what they find at the front e.g one in four with alcohol/substance dependence. The IAPT practitioners at the front line have little understanding of the prevalences, multiplicity and complexity  of disorders they will find. Training is insufficient to allow them  to distinguish PTSD from a specific phobia, situational bound panic attacks from panic disorder. This is legitimated by the IAPT Manual that claims the Organisation doesn’t make diagnosis, making treatment like playing roulette. No wonder IAPT therapists are burnt out. 

Unsurprisingly I found that when I examined 90 IAPT clients independently using a standardised semi-structured interview the recovery rate was just 10% Scott (2018) https://doi.org/10.1177/1359105318755264 . The Government has never independently audited any of the services that it is spending £500 million on. The Minister for Mental Health, Nadine Dories  has said £2.5 million is to be spent on ‘new approaches to support children who have experienced complex trauma’ she appears not to know that the whole notion of ‘complex trauma’ is a matter of considerable debate. Doubtless many have been stressed by the pandemic, but it would make more sense to wait for the storm to pass and assess the storm damage before throwing money at it. There is a danger in pathologising normal responses to an abnormal  situation and not being guided by evidence based interventions.

Dr Mike Scott

On What Basis Are Talking Therapies Out Of Bounds To The Care Quality Commission?

The Care Quality Commission (CQC) has just called the Government to task for blanket Do Not Resuscitates (DNRs) applied at the start of the pandemic. But the CQC is not allowed to investigate the quality of the Improving Access to Psychological Therapies (IAPT) services for those with mental health difficulties. Could there be a more glaring example of the disparity between physical and mental health services?

 

The IAPT service has had a decade of going under the radar of independent public scrutiny, despite Government expenditure of over £4billion. Strangely the National Audit Office (NAO) has no intention of mounting an audit (see recent post), citing preoccupation with Covid and its’ earlier preoccupations with the collapse of Carrillion and the provision of generic medicines. IAPT is responsible to NHS England but staff at the Department of Health also have key positions in IAPT. NHS England are likely to claim that they are ‘too busy’ to address trivial matters like conflicts of interest, reacting like the NAO. The Government will likewise claim preoccupation to avoid addressing sensitive matters.

The CQC can investigate whether the needs of those in Care Homes are being served and can champion the plight of residents, who is to champion the needs of those with mental health difficulties. Organisations such as Mind often have funding arrangements with IAPT. The  British Association for Behavioural and Cognitive Therapies (BABCP) and the British Psychological Society (BPS) regularly give pride of place to IAPT luminaries with rare opportunities for opposing views to be expressed.  The result is a groupthink within these organisations. 

Dr Mike Scott

 

IAPT Is Efficacious For What and By What Psychological Mechanism?

IAPT claims to be efficacious but there is no specification of for what. No treatment is universally effective, an evidence supported treatment (EST) has by definition a clearly defined focus either a disorder or a particular syndrome. There is no EST for IAPT’s fuzzy construct of ‘anxiety/depression’,  for which it claims a 50% recovery rate. IAPT’s therapists pluck an ICD-10 (World Health Organisation) code out of thin air to describe a clients functioning, but paradoxically claims that the agency does not make a diagnosis (IAPT Manual)! This process gives respectability without accountability.

A psychological therapy must work via a recognised psychological pathway, it is not sufficient that the intended target is a psychological problem/disorder (however fuzzily defined).  In not one of the 100+ missives from IAPT staff to GPs that I have seen has the mechanism of client change been clearly indicated. Rather a collection of keywords from the CBT literature is offered up, favourites in this fruit salad include, ‘reprocessing the trauma’, ‘behavioural activation’, ‘cognitive restructuring’ never is there specificity, for example ‘reversed the negative alterations in cognitions about self, others and world that led to client no longer meeting diagnostic criteria for PTSD’. Fake psychological therapies rule.

Little wonder that clients and GPs are bewildered by the IAPT process – a home for the bemused/befuddled awaits, maybe a high PHQ9 score will be the entry ticket, with promised teletherapy with an IAPT worker! 

Dr Mike Scott

National Audit Office Offers No Evidence That The £0.5 Billion, Per Year, Spent on Talking Therapies Is Value For Money

The £4 billion plus spent on the Improving Access to Psychological Therapies (IAPT) programme over the last decade could have been better spent improving the lot of Nurses. On March 6th 2021, I received a reply from the National Audit Office (NAO), ironically from the Director of the Health value for money Team, saying that it had no intention of mounting an investigation into UK Government’s, Improving Access to Psychological Therapies (IAPT) programme. The Director adds ‘but you raise important issues – around data quality, levels of performance, outcome measurement, and what has been achieved for the spend – that would be important to cover in any report we consider on mental health services’.  

The Director informed me they have been preoccupied with the effects of Covid!  In 2017 the NAO  initiated an investigation into IAPT  but a year later it was discontinued because of ‘Brexit, the collapse of Carillion and concerns about spending on generic medicines’. The NAO never published their findings.  It seems that the NAO will always have an excuse to kick a focus on IAPT into the long grass. But in 2016 it had asked the Department of Health  to investigate why  IAPT was exempt from Care Quality Commission scrutiny.  The DOH made no response – friends in high places?

There appears to be an implicit assumption that just throwing money at mental health must be good. The NAO has signally failed to manage the public purse. At a time when this purse is near empty, and there are clearly pressing needs amongst Care and Nursing staff, this is appalling. 

Dr Mike Scott

 

Beware of Claims for Teletherapy

there is insufficient evidence that teletherapy (FaceTime, Zoom, Whats App) is superior to telephone assisted therapy,  that is the take home message from a just published review by Markowitz et al (2021) in this months American Journal of Psychiatry Am J Psychiatry 2021; 178:240–246; doi: 10.1176/appi.ajp.2020.20050557. Interestingly the preference of some clients with social anxiety disorder and PTSD is for telephone assisted therapy.  Markowitz et al (2021) also regard the claim that Teletherapy is as good as in person therapy as not proven. They voice a fear that remote therapy could become the new norm because of cost and convenience than because of evidence of equivalence with in-person therapy. Whilst there is undoubtedly a convenience value to teletherapy for clients and therapists with availability problems, there are also disadvantages such as managing a client who has become suicidal, missing non-verbal cues because of ‘talking heads’ together with technical problems, such as a poor internet connection, freezing screens etc. Further the poor and the elderly may not be able to afford the cost.

Markowitz et al (2021) opine that for the duration of the pandemic teletherapy may be very important but long term it should become, like telephone assisted therapy a useful option. I would hope so. But looking at the way in which IAPT has dominated the field with its low intensity (low cost) interventions bereft of a credible evidence base, I suspect teletherapy will continue to be a mainstay despite the jury being out on its’ efficacy. 

 

Dr Mike Scott