according to a study conducted by the US Center for Disease Control (CDC) in June 2020. With 31% suffering anxiety/depression symptoms, 26% trauma/stressor-related disorder symptoms, 13% started or increased substance use and 11% seriously considered suicide. Doubtless there would be similar findings if such a study was conducted in the UK now. At face value we have a ‘mental health pandemic’. But actually the figures are almost certainly an artefact of relying on self-report measures says Dr Pies writing in the Psychiatric Times in October 2020. In his article he points out that reliance was placed on a self-report measure the PHQ-4 and no diagnostic interviews were conducted. The article link is https://cdn.sanity.io/files/0vv8moc6/psychtimes/7f0135f1e41fe8c73ef52e3c6e42aedf04cffadc.pdf
But in the UK the Improving Access to Psychological Therapies (IAPT) programme bases its treatment of common mental health disorders purely on self-report measures. In terms of its own modus operandi they have probably been unwittingly denying access to great swathes of people since the onset of the pandemic! It is noteworthy that they have not mounted a defence that they are too under resourced to even begin to see such large numbers of people, this may have bestowed some credibility. Arguably, it has become the Denial of Access to Psychological Therapies Programme (DAPT). IAPT cannot have it both ways either it has massively denied treatment throughout the pandemic/ failed to acknowledge a grave mental health crisis or its’ modus operandi is fundamentally flawed! Either way there is need for an independent public inquiry into IAPT.
this is the primary outcome measure used in a just published study of CBT for persecutory delusions https://babcpmail.com/AQ0-7G5L5-2KPHRR-4HXKEC-1/c.aspx. But would the typical person suffering from schizophrenia recognise this metric? What if convictions take a variable course and are mood dependent? What is going on here? Unrestrained by such questions Freeman et al (2021) proclaim in their advertisement for the 5 day online course for the Programme:
‘it is the most effective psychological treatment for persecutory delusions. Half of patients have recovery in their persecutory delusion with the Feeling Safe Programme’
‘Recovery’ here has a meaning far removed from common parlance. ‘When I use a word,’ Humpty Dumpty said, in rather a scornful tone, ‘it means just what I choose it to mean – neither more nor less.’ —LEWIS CARROLL, Through the Looking-Glass, 1871. If my conviction about the likelihood of being flooded fell to less than 50%, I would still be wanting to relocate!
Freeman et al (2021) are evaluating their own Feeling Safe Programme but no mention that therefore their study might be prone to allegiance bias. The same therapists administered the Feeling Safe Programme and the comparison Befriending Programme. Given that the therapists knew that the hypothesis was that the former would prove superior to the latter, they are likely to be more enthusiastic about the CBT. Twenty sessions were to be delivered in 6 months in each modality but in the event more sessions were delivered in the CBT. Thus the possibility of allegiance bias amongst the therapists cannot be ruled out. It is therefore not surprising that a statistically significant difference was found between the two arms of the study. But this does not necessarily demonstrate the added benefit of CBT – a further confounding factor is that 71% of those in befriending were on antidepressants compared to 50% in CBT.
Freeman et al (2021) make the common cry of all researchers for more research, but there is no mention of the need for independent replication. This latter is particularly important as previous studies have not demonstrated the added value of CBT for persecutory delusions.
Inappropriate Outcome Measure
Clients in CBT were encouraged to take a 6 session module ( the Feeling Safe Module) targetting threat beliefs, how can the latter then be a credible outcome measure? Broader measures such as functioning as I was before I became paranoid or even as I was when I was least paranoid would have been more credible primary outcome measures. Further the secondary outcome measures used were all based on self-report measures, there was no standardised diagnostic interview conducted. Whilst diagnostic labels were affixed at entry into the study ( on what basis is not clear), they were ignored with regards to outcome.
Is The Effect Size Found Meaningful?
The effect size for the primary outcome measure was a Cohen’s d of 0.86, Freeman et al (2021). The effect size for total delusions score on PSYRATS was d=1.2 Freeman et al (2021) celebrate this large effect size as comparable to that found in trials of CBT for anxiety disorders. But in terms of the primary outcome measure the average person undergoing CBT improved by less than one standard deviation compared to the average person who was befriended, this is shown diagrammatically below, does this amount to a real world difference? The economic analysis promised in the pre-trial protocol was not included in the paper, leaving it an open-question as to whether the CBT is worth the added investment.
Eminence-based Rather Than Evidence-based
Advocates of the Feeling Safe Programme, are claiming more than is known, doubtless BABCP and IAPT will seize on it and control how CBT is to be conducted with this population, extending their empire. Well the study was published in Lancet Psychiatry after all? The CBT therapist should be sceptical, but regrettably training courses seem not to equip them for this, I wonder why? Perhaps I am paranoid?
‘we can only deal with one problem, because that fits into the 6 sessions of therapy that we start with’, but the Improving Access to Psychological Treatments (IAPT) service makes no public declaration of this. Clients want a holistic approach in which all their problems are catered for. It is magical thinking to believe that a) a mental health problem can be resolved in 6 sessions b) the benefits gained from addressing the chosen mental health problem will, by a process of osmosis, resolve the other mental health problems. This represents delusional Organisational thinking, unfortunately I think it would take a lot more than 6 sessions to treat!
Recently I saw Ms X and she related to me her two sojourns through IAPT. I also had access to the IAPT correspondence, for confidentiality reasons, some of the details have been changed:
Five years a ago, Ms X found out that she had been adopted, she felt that she had never fitted in with her adoptive family, though they were kind. She felt that she had always been a ‘worrier’, her adoptive mum had chronic health problems and shortly after learning of her adoption she became concerned over any blemish on her skin. Ms X saw her GP and she advised self-referral to IAPT. She had a telephone assessment with a Psychological Wellbeing Practitioner and was advised that her PHQ-9 score was normal and her GAD-7 score at ‘caseness’. But no diagnosis was given. A letter from IAPT indicated that she ‘agreed to attend a worry management course’ but she said only a group programme was on offer. Ms X dropped out after attending one group session. Her GP had recorded that the treatment had not helped. I assessed her using a standardised diagnostic interview and it was clear that she had been suffering from illness anxiety disorder and general anxiety disorder (GAD) at the time of seeking help form IAPT and her diagnostic status was unchanged by IAPT’s ministrations.
Two years later she was at work, when her hair got caught in machinery at work causing a scalp injury. However the injury was under the hairline and not visible, but she could feel an indentation on her scalp. She developed a phobia about being around machinery leading to poor attendance at work and possible disciplinary action. The accident re-ignited her illness anxiety disorder that had been in remission for about 6 months. I noted that she continued to meet diagnostic criteria for GAD. Her GP advised self-referral to IAPT and she had a telephone assessment with a Trainee Psychological Wellbeing Practitioner, both PHQ-9 and GAD-7 scores were at ‘caseness’. No diagnosis was given. Ms X was told that they could only treat one of her problems and she chose her health anxiety concerns. She was placed on a 6 week waiting list for the Silver Cloud computerised CBT. During, the course of her cCBT she had 4 interactions with IAPT staff responsible for the smooth functioning of the Silver Cloud programme. They said that she was ‘depressed and anxious’ but gave no diagnosis. During treatment her specific phobia was not addressed at all. The diagnostic interview that I conducted revealed comorbid illness anxiety disorder and GAD but she was not depressed. She understood that there was to be a review of her progress at the end of cCBT to see what if any further help might be appropriate. This never happened. The Silver Cloud programme had no impact on her diagnostic status. IAPT’s treatment was ‘in the Clouds’.
This case raises important questions:
Why was a minimalist intervention repeated when the first such intervention had not worked?
Why are the least well-trained clinicians given the power to direct treatment?
Why are the least well-trained clinicians given the power to re-direct treatment?
Why is IAPT allowed to behave in a way that would not be tolerated in physical care vis a vis a focus on just one problem and continued management by the most junior clinician when treatment fails?
Where is the publicly funded independent audit of IAPT?
Unfortunately, this is not an isolated case, my own review of 90 cases suggests just a 10% recovery rate Scott (2018) https://doi.org/10.1177%2F1359105318755264) . There has been a dereliction of duty by NHS England, Clinical Commissioning Groups and the National Audit Office. The British Psychological Society has rubber stamped whatever IAPT has proposed. The British Association for Behavioural and Cognitive Psychotherapy have become an IAPT mouthpiece, its’ journal CBT Today intolerant of dissent.
The National Institute for Health and Clinical Care Excellence (NICE) rightly considers the results of randomised controlled trials in advocating particular psychological therapies, but has not assessed whether, as implemented, they represent an added value compared to previously available therapies. Consider a new drug that is of proven efficacy in randomised controlled trials, NICE would understandably look positively at it, but before recommending it would want to know about side effects and the proportion of people discontinuing use. However NICE seems blissfully unaware that for the psychological treatments that they recommend, when delivered in routine practice, only one half of people tolerate more than one treatment session [Improving Access to Psychological Therapies (IAPT) Annual report 2019-2020 https://files.digital.nhs.uk/B8/F973E1/psych-ther-2019-20-ann-rep.pdf,. But they do know that there is no independent evidence of greater remission since the inception of IAPT – their silence on this point is deafening.
The NICEimpact mental health document (2019) asserts, p4 ‘The IAPT programme offers NICE-recommended treatments’ for common mental health disorders in adults. No it does not and what is worse still is that NICE have never bothered to check. NICE has been simply the voice of the power holders in mental health and not the consumers.
The usual metric employed by NICE is Quality Adjusted Life Years (QUALY), as a general rule of thumb new interventions are recommended if the cost of one QUALY does not exceed £20,000. But a QUALY can only be assessed against the benchmark of the previous standard drug/service i.e there is a presumption that this is reliably known. However NICE has operated without this data, as such its recommendations on mental health and in particular on depression and the anxiety disorders are blind. Yet organisations such as IAPT (Improving Access to Psychological Therapies) establish their legitimacy to paymasters (NHS England and Clinical Commissioning Groups) by claiming the NICE seal of approval. NHS England and CCG’s prefer to nod to this ‘seal’ rather to enquire about IAPT’s claims, much less to set up an independent body to address the veracity of claims. This is not too surprising as there is a semi-permeable membrane between the Department of Health and service providers. Conflicts of interest have not been addressed.
Determining a QUALY with regards to mental health is not easy, but one QUALY could reasonably be interpreted as the cost of achieving the absence of meeting diagnostic criteria for a recognised psychiatric disorder for a year for a client, following say an IAPT intervention, this would be compared with the typical cost of achieving this goal with the same type of client in pre IAPT services. But no follow up of IAPT clients has been conducted that independently tracks diagnostic status. NICE is saying more than it knows, but at whose behest?