Half of IAPT Clients Attend Only One Treatment Session

according to the UK Governments Improving Access to Psychological Therapies (IAPT)  annual report for 2019-2020 -https://files.digital.nhs.uk/B8/F973E1/psych-ther-2019-20-ann-rep.pdf,  489,547 people curtailed involvement after having one treatment appointment,  whilst 606,192 had two or more treatment sessions. If half of people never returned to a particular Cafe in their locality it would not be a good advertisement. But the IAPT Cafe is the only affordable one for most people, with a third of its’ clientele returning for further courses of ‘sustenance’, Hepgul et al (2016) https://doi.org/10.1186/s12888-016-0736-6.  Doesn’t sound like this Cafe confers health.

This haemorrhaging of clients is not a feature of the NICE recommended treatments, yet IAPT claims fidelity to such treatments! What then does one make of IAPT’s claim of a 50% recovery rate? This would be a fitting subject for Radio 4’s ‘More or Less’ statistical programme. To set the context, of 1.69 million referrals to IAPT in 2019-2020, 1.17 million left the starting gate, 30.77% (almost 1 in 3) were non-starters. Further only 1 in 3 (36.8%) got around the course (defined curiously by IAPT as attending 2 or more treatment sessions). IAPT’s terrain is much like that of the Grand National horse race. The ‘50% recovery rate’ refers to the significant minority who cross IAPT’s finishing line. Thus even using IAPT’s own yardstick  the true recovery rate is much less than 50%.

With regards to those who cross IAPT’s finishing line, there is no indication that their ‘success’ is lasting. It is not known what proportion of them ever ‘race’ again. Thus, the true recovery rate is likely to be far less than 50%. My own independent study of 90 IAPT clients, Scott (2018) https://doi.org/10.1177%2F1359105318755264  suggests that in fact only the tip of the iceberg, 10% , recover in any real world sense.

It serves all Organisation’s well to be vague about its’ criteria for success, they almost certainly operate with a confirmatory bias, cherry picking data that would justify its’ existence in the eyes of its paymaster. Biases or heuristics do not necessarily operate consciously but are nonetheless powerful and likely to be employed if survival is at stake. See for example Lilienfeld and May’s (2015) https://doi.org/10.1002/9781118625392.wbecp567 critique of reliance on self-report measures, a particular penchant of IAPT. These authors also point out that the only sure way of de-biasing is to have independent review, but IAPT has never been subjected to publicly funded independent review. 

Dr Mike Scott

 

IAPT Out Of Its’ Depth

a just published paper in the British Journal of Clinical Psychology by Martin et al https://doi.org/10.1111/bjc.12314 concludes:

‘Improving Access to Psychological Therapies provision and research at present does not adequately consider the complexity of its clientele in the context of treatment outcomes and service delivery’

The authors suggest that practitioners bear the following in mind:

  • Improving Access to Psychological Therapies (IAPT) has significantly increased access to psychological therapies within primary care over the last decade, though it is unclear whether its interventions are sufficiently tailored to meet the actual levels of complexity of its clientele and prevent them from needing onward referral to secondary care as originally envisaged.
  • Given the ongoing focus on and investment in IAPT informed developments into long-term conditions and serious mental illness, this review considers whether additional elucidation of the model’s original objectives is required, as a precursor to its expansion into other clinical areas.
  • The review indicates that there is a stark lack of data pertaining to the generalisable, real-world clinical benefits of the IAPT programme as it currently stands.
  • Recommendations are provided for future areas of research, and practice enhancements to ensure the value of IAPT services to clients in the wider context of NHS mental health services, including the interface with secondary care, are considered.

I did throw IAPT a lifebelt with my paper ‘Ensuring IAPT Does What It Say On The Tin’ published in the BJCP  in
 
March 2021  https://doi.org/10.1111/bjc.12264 but the rebuttal from Kellett et al in the same issue of the Journal
 
DOI:10.1111/bjc.12268 suggests that  my comments fell on deaf ears.
 
 

Dr Mike Scott 

When Mental Health Screening Makes You Want to Scream

assessment in the Improving Access to Psychological Therapies (IAPT) Service takes up 25% of all resources, yet in the NICE approved protocols for depression and the anxiety disorders assessment takes about 8% of resources       (roughly an assessment session for 10-15 treatment sessions). Much of the IAPT assessment consists of telephone completed screening questionnaires by contrast the assessment in the NICE protocols consists largely of a reliable standardised diagnostic interview. But there is no reason to believe that the screening measures in IAPT (PHQ-9 and GAD-7) are pertinent to the client’s problems. Despite this in IAPT, these measures are re-administered every session and often made the focus of discussion, thus the actual total time spent in IAPT on ‘assessment’ is likely much more than 25% of the budget. The added value is? IAPT has a credibility gap. Is it really credible that with such a skewed distribution of resources, that IAPT should claim success comparable to that found in the randomised controlled trials that are the basis for NICE recommendations? IAPT claims fidelity to NICE protocols, so that it is not divorced from its’ paymasters NHS England/Clinical Commissioning Groups, but it is a well known philanderer. It provides no evidence of fidelity, just protestations.

I hear that IAPT is looking at introducing artificial intelligence into the assessment process! Whilst there are attempts to develop an algorithim for suicide risk by looking at records etc, the outcome is likely to be some marrying of this with clinician expertise. But this goal is quite a challenge. A meaningful algorithim for IAPT’s assessments  is likely to be a whole different ballgame. Time would be better spent doing the simple things such as really listening to clients and making a reliable diagnosis to direct treatment, this would be an exercise in intelligence. 

IAPT represents an extreme case of the tail wagging the dog when it comes to screening. A just published editorial in the Journal of the American Medical Association by Mitchell Katz, shows the more general problem of screening:

 
Editor’s Note
June 14, 2021

A Response to Excessive Screening Questions

JAMA Intern Med. Published online June 14, 2021. doi:10.1001/jamainternmed.2021.2925

‘Recently, JAMA Internal Medicine published a firsthand account of a trauma survivor who had disclosed over a series of years on multiple self-administered screenings that she had experienced trauma,1 yet none of her health care clinicians had ever followed up with her or provided any support or resources. In reading her account, I wondered how many of her clinicians had even seen the screening questionnaires she completed.

Standardized screening questionnaires allow primary care clinicians to learn important information about patients, especially in psychosocial areas (eg, depression, anxiety, substance use) that can be difficult to assess in short appointments. Adding to their efficiency, they can be completed in the waiting room. But for them to be useful, they have to be read, and the appropriate resources must be available.

Just as “alarm fatigue” can result in not paying attention to important warnings from electronic health records, use of screening questionnaires performed more often than necessary can deluge clinicians with more information than they can incorporate in a visit, decreasing the efficiency of the visit and leading to cynicism on the part of patients (eg, “Why do they keep asking me if I am depressed, when I keep telling them I am not?”) and on the part of primary care clinicians (eg, “Why are my patients repeatedly given these screeners, when I dealt with this issue on the last visit?”).

In this issue of JAMA Internal Medicine, Simon and colleagues2 estimated the proportion of standardized screenings performed at 24 federally qualified health centers in 2019 that were excessive, defined as performed when not recommended. Six screeners were evaluated (depression, anxiety, smoking status, passive smoke exposure, health literacy, and preferred learning style), all of which were tied to national performance metrics. The authors found that 34.9% of all screenings performed (2 067 152 of 5 917 382) were excessive’.

Dr Mike Scott

 

When Does Psychological Therapy Count As A Success?

always, if you lower the methodological bar low enough. The just published study by Chalder et al (2021), is an exemplar,  focussing on cognitive behaviour therapy for people with persistent physical complaints (PPS) https://doi.org/10.1017/S0033291721001793:

  • that there was no significant difference in outcome on the primary outcome measure, the self-report Work and Social Adjustment Scale
  • the authors of their report were evaluating their own protocol for PPS [hitherto known as Medically Unexplained Symptoms (MUS)]
  • there was no independent clinical assessment of outcome
  • the control group received ‘standard medical care’, there was no control for attention (the treatment group received 8,  1 hour sessions) 
  • there was no evaluation of effectiveness in a non research setting

Tolin et al ( 2015) https://doi.org/10.1111/cpsp.12122 have presented a clearly defined methodological bar as to what constitutes an Empirically Supported Treatment (EST), that has been adopted by  the American Psychological Association. Far from clearing this bar Chalder et al (2021) protocol  failed on each of the 5 criteria above. In addition Chalder et al (2021) fail to mention that total reliance on self-report measures, this makes the study especially prey to demand characteristics, in that those given attention are likely to want to please the therapists and not to feel they have wasted their own time by indicating a better response than otherwise.

Chalder et al (2021) fail to reference any work that challenges the very concept of MUS e.g Geraghty and Scott (2020) https://doi.org/10.1186/s40359-020-0380-2. The theoretical basis for Chalder et al’s CBT (2021) is that ‘Patients with PPS can develop unhelpful cognitions and behaviour which can consequently lead to a reduction in daily functioning, reduced quality of life, and an increased susceptibility towards developing depression and anxiety’. These authors inform the reader that all those in the study met criteria for fibromyalgia, but by Chalder et al’s (2021) rationale all with a persistent physical symptom require psychological therapy, this would just about swallow up all mental health resources in primary and secondary care. 

 In their statement of Conflict of Interest the authors Chalder et al (2021) indicate their background in the training of IAPT staff, unfortunately it is likely that the treatment protocol will find its way into the organisations ministrations, before any independent evaluation, despite the authors call for further research .  

 

References

Chalder T et al (2021). Efficacy of therapist-delivered transdiagnostic CBT for patients with persistent physical symptoms in secondary care: a randomised controlled trial. Psychological Medicine 1–11. https://doi.org/10.1017/S0033291721001793

Geraghty, K., & Scott, M. J. (2020). Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified. BMC psychology, 8(1), 13. https://doi.org/10.1186/s40359-020-0380-2

Tolin, D. F., Mckay, D., Forman, E. M., Klonsky, E. D., & Thombs, B. D. (2015). Empirically supported treatment: Recommendations for a new model. Clinical Psychology: Science and Practice, 22(4), 317–338. https://doi.org/10.1111/cpsp.12122

Who Is Monitoring The Quality of Primary Care Mental Health Services?

Nobody, Clinical Commissioning Groups (CCGs) confine themselves to operational matters, number of patients seen, waiting lists.  The Improving Access to Psychological Therapies (IAPT) service has been allowed to self-monitor since its’ inception in 2008.  The National Audit Office abandoned its’ investigation of IAPT because of competing priorities citing the Carillion debacle amongst others in June 2018. Who is listening to the voice of the recipients of the mental health services?  

The mantra appears to be to get everyone to talk about mental health, especially celebrities, get everyone involved in mental health, teachers etc, secure more funding for anything with a mental health flavour on the basis that ‘it must be good’. But frenetic activity does not equal making a real world difference, achieving this has to be carefully monitored.

It goes without saying that we all need a more caring society nationally, for example assisting those who have been self-isolating for over a year to gradually venture out.  From an international perspective we should be giving a £1bn a year to fund the provision of vaccines in poorer countries. The need for compassion is never redundant.  But political correctness about mental health can obscure fully engaging with those in most need. 

Dr Mike Scott