Critiquing IAPT and The Psychologist

The October issue of The Psychologist features a letter of mine and the Editor’s response:

‘In the September issue, Ross Harper – CEO of Limbic, providing AI software for mental healthcare – extolled the virtues of their collaboration with four IAPT services. The supposed gains were all in operational matters, e.g. reduced time for assessment, with no evidence that the AI has made a clinically relevant difference to client’s lives. 

This is merely the most recent example of the biased reporting of The Psychologist with regards to IAPT. I raised these concerns in a 2014 submission, ‘IAPT – The Emperor Has No Clothes’, and the Editor rejected it with the line ‘I also think the topic of IAPT, at this time and in this form, is one that might struggle to truly engage and inform our large and diverse audience’. This response was breathtaking given that IAPT was/is the largest employer of psychologists. 

Fast forward to 2018, and I had published a paper ‘IAPT – The Need for Radical Reform’ in the Journal of Health Psychology, presenting data that of 90 IAPT clients I assessed independently using a standardised diagnostic interview only 10 per cent ‘recovered’ (in the sense that they lost their diagnostic status). This contrasts with IAPT’s claimed 50 per cent recovery rate. The paper has received only a passing mention in the pages of The Psychologist [‘Letters’, Flatt and Lido, April 2021]. This year I wrote a rebuttal of an IAPT inspired paper that was published in the British Journal of Clinical Psychology, ‘Ensuring IAPT Does What It says On The Tin’, but again no mention of this debate in The Psychologist.

In my view the BPS is guilty of a total dereliction of duty to mental health service users in failing to facilitate a critique of IAPT. If psychologists cannot pick out the log in their own eye, how can they pick out the splinter in others? 

Dr Mike Scott 
michaeljscott1@virginmedia.com

Editor’s reply: Funnily enough, we’ve also received strong criticism over the years for being too critical of IAPT! While I stand by my ‘at this time and in this form’, those are ever-shifting considerations and I’m pleased to now be in contact with you about a potential contribution to the magazine’.

 Further to the editor’s reply I have submitted an article ‘Spin In CBT’ see below, alas the Editor said ‘no’ . I am off to a home for the bemused and befuddled.

The Spinning of CBT

 

Michael J Scott, Joan S Crawford and Keith Geraghty

 

There has been a massive expansion of psychological therapy services since the inception of the UK Government’s, Improving Access to Psychological Therapies (IAPT) Service in 2008. Offering principally and allegedly, cognitive behaviour therapy (CBT), by 2023/24 the IAPT Service hopes to see 1.9 million people a year [IAPT Manual, August 2021]. This represents a quarter of the community prevalence of depression and anxiety disorders. The intent of IAPT is clearly laudable, but it is much less clear that it meets the needs of clients? Is it worth the money? Given that the typical IAPT therapist earns £35K a year (twice that of a Care Assistant), and with salary costs reaching over £0.5 billion per year by 2023/24, there is a pressing need for independent audit.

By Services Marking Their Own Homework

The first author was alerted that all may be not well at IAPT’s coalface, when as an Expert Witness to the Court he reviewed 90 cases, treated with alleged CBT, and found a recovery rate i.e loss of diagnostic status, in just 10% of cases, using a standardised diagnostic interview Scott (2018). This applied whether or not service users were treated before or after their personal injury. This ‘tip of the iceberg’ response, contrasts sharply with IAPT’s claimed recovery rate of 50%. Curiously there has been no publicly funded independent audit of IAPT which would help to settle matters.

To Mask A Fault Line In the Provision of Routine Psychological Therapy

There is a fault line in IAPT’s approach which we thought might be rectifiable Scott (2018) [IAPT- The need for radical reform, Journal of Health Psychology] and Scott (2021) [Ensuring IAPT does what it says on the tin. British Journal of Clinical Psychology], but which may in fact make its’ ‘building’ of services inherently unsafe. IAPT declares usage of the ICD-10 code (the World Health Organisation’s labelling system for all disorders). The recent IAPT Manual (August 2021) https://www.england.nhs.uk/wp-content/uploads/2018/06/the-iapt-manual-v5.pdf recommends that IAPT clinicians give at least one code to each client, to characterise their debility. But nowhere in the Manual does it suggest that IAPT clinicians make a diagnosis. An ICD-10 code is only as reliable as the diagnosis made. The Manual claims that NICE Guidelines are based on ICD-10 codes and that IAPT is therefore NICE compliant.  However the treatments recommended by NICE are all diagnosis specific, it follows that if there is no diagnosis there can be no fidelity to a NICE protocol. A key part of IAPT’s narrative is to gloss over that IAPT’s interventions are based, not on diagnosis, but on ‘problem descriptors’. The silent assumptions are that: a) there would be reliable agreement (reliability) between clinicians about what would constitute a client’s main problem and b) there is a body of evidence that a problem descriptor acts as a key to unlock the door to a specific protocol. Further that the specific protocol has been demonstrated to confer an added value, over and above an active placebo, for the chosen problem descriptor. There is an assumption of clinical utility. But there is no empirical evidence for either a) the reliability or b) the clinical utility. Whilst IAPT interventions contain elements of protocols used in randomised controlled trials there is no evidence of fidelity to such protocols i.e of comprehensive coverage of treatment targets for a disorder and matching treatment strategies.

A Pandemic of Spin

 

Spin has been identified in half the abstracts of papers in psychiatry and psychology journals Jellison et al (2020). In this context spin referred to a claim that an experimental treatment was beneficial, despite a statistically nonsignificant difference for the primary outcome or to distract the reader from statistically nonsignificant results.  IAPT claims its sojourn into the treatment of persistent physical symptoms (PPS), such as chronic-fatigue syndrome, is evidence-based, but it is an exemplar of precisely what Jellison et al (2020) identified. Chalder et al (2021) compared the effectiveness of transdiagnostic cognitive behavioural therapy (TDT-CBT) plus standard medical care (SMC) to SMC alone. The primary outcome measure was the Work and Social Adjustment Scale (WSAS). There was no significant difference in outcome on this measure but in the abstract  Chalder et al (2021) proclaim  their intervention ‘may be helpful with a range of PPS’, with an appeal to some outcomes on secondary measures.

But arguably there are other additional markers of spin a) when the primary outcome is not independently assessed b) when the primary outcome is not clinically relevant and c) when there is no prior specification of what would constitute a minimally important difference in the primary outcome measure. In this connection none of the studies used to justify IAPT’s low intensity interventions have involved an independent assessor using a standardised diagnostic interview. For example, the Stress Control (SC) Programme is the most commonly delivered first line group intervention in IAPT Dolan et al (2021). In the SC studies outcome was assessed purely with self-report measures without any guarantee that the measures related to the disorders that the clients were suffering from. Dolan et al (2021) made no attempt to explain a) what a change of X on these measures would mean as opposed to a change in Y and b) whether the changes of scores would be meaningful to a client. The study showed  an effect size difference in outcome between SC and active comparison conditions and passive controls of 0.12-0.15, but this is so small as to be of doubtful clinical significance.  Nevertheless under a heading of ‘Practitioner Points’ they declare ‘SC is appropriate and effective for mild to moderate anxiety and depression’. Dolan et al (2021) found that the SC studies had a mean quality score of 18.21 but fail to mention that this is much lower than the mean score of 27.8 [Ost (2008)] in CBT studies. Ost (2008) commenting on a series of studies that had a mean score of 19.6 declared that this set of studies could not therefore be considered an empirically supported treatment (EST). IAPT does not provide EST’s in their low intensity provision. Further there is no evidence of fidelity to ESTs in the high intensity interventions. Additionally the dosage of therapy routinely delivered in high intensity IAPT therapy falls far short of that advocated in randomised controlled trials of CBT.

The Genesis of Spin

Spin is often related to undeclared conflicts of interest. In the Dolan et al (2021) study all authors declared no conflict of interest. But the corresponding author for the Dolan et al (2021) study is a programme director of IAPT and another of the authors has IAPT involvement. Unfortunately this is not an isolated example, Scott (2021) challenged a similar non-disclosure by these authors earlier this year.

A National Failure to Address Spin

The National Audit Office (NAO) began an investigation into the IAPT service but then stopped it in June 2018 without publication of findings. Following a Freedom of Information request to the NAO, the first author was told in a communication dated February 17th 2020 that the investigation was halted because of variously, the collapse of Carillion and Brexit, with no intention of resuming its’ investigation. Further the NAO response added ‘The investigation was not intended to comment on clinical judgements or the extent to which services meet patient needs’! IAPT has successfully enlisted NHS England, Clinical Commissioning Groups (CCGs), the British Psychological Society (BPS) and the British Association for Behavioural and Cognitive Psychotherapy (BABCP) to proclaim its’ ‘world-beating’ [Dr Claire Murdoch, NHS England Mental Health Director, Health Business August 26TH 2021] status. IAPT is however eminence-based not evidence-based.

The Demise of The Psychologist’s Role

IAPT is the major employer of psychologists, who risk becoming deskilled by the climate change brought about by the Service.  Psychologists tend to stay in IAPT for a few years before heading for the exit to secondary care of private work. This leaves an IAPT workforce bereft of the means of critical appraisal of their work. Staff are ill-equipped to challenge the edicts from on high and disagreement is seen as disloyalty resulting in burn out and worse.

  1. Michael J. Scott, Consultant Psychologist, Liverpool, UK

 

  1. Joan S. Crawford, Counselling Psychologist, Mersey Care NHS Foundation Trust, Chronic Pain Management Service (CPMS), St Helens. https://orcid.org/0000-0001-6400-1158

 

  1. Keith Geraghty, Centre for Primary Care, Division of Health Sciences and Population Health, University of Manchester, UK. https://orcid.org/0000-0001-5060-5022

           

Corresponding author:   Michael J Scott michaeljscott1@virginmedia.com

 

 

 

 

 

Key resources

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.

 

Dolan, N., Simmonds-Buckley, M., Kellett, S., Siddell, E., & Delgadillo, J. (2021). Effectiveness of stress control large group psychoeducation for anxiety and depression: Systematic review and meta-analysis. The British journal of clinical psychology60(3), 375–399. https://doi.org/10.1111/bjc.12288

Jellison S, Roberts W, Bowers A, et al. BMJ Evidence-Based Medicine 2020; Evaluation of spin in abstracts of papers in psychiatry and psychology journals  25:178–181.

Scott M. J. (2018). Improving Access to Psychological Therapies (IAPT) – The Need for Radical Reform. Journal of health psychology23(9), 1136–1147. https://doi.org/10.1177/1359105318755264

 

Scott M. J. (2021). Ensuring that the Improving Access to Psychological Therapies (IAPT) programme does what it says on the tin. The British journal of clinical psychology60(1), 38–41. https://doi.org/10.1111/bjc.12264

 

 

 

 

 

 

 

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The Improving Access to Psychological Therapies (IAPT) Service Fails To Make the Case for Its’ High Intensity Therapy

 

 

IAPT claims a 50% recovery rate when comparing Service entry and exit scores. It does so without any differentiation between treatment modality: low intensity CBT, high intensity CBT or the combination. However, a study from Northern Ireland focussing solely on the effectiveness of low intensity CBT also claims a recovery rate of 50% https://www.dropbox.com/s/s32zabv1ffzyn9q/IAPT%20%20and%20N.Ireland%20data.docx?dl=0 [Full paper reproduced below] using just Psychological Wellbeing Practitioners (PWPs). This must raise doubts about whether there is any added value to high intensity CBT. Alternatively IAPT’s way of assessing service effectiveness is seriously flawed. 

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A New Mental Health Service Model for NI: Evaluating the Effectiveness of Low Intensity CBT (LI-CBT) delivered in primary/community care settings

Policy Briefing 8th March 2017

Dr Karen Kirby, Orla McDevitt-Petrovic (MSc), Dr Orla McBride, Prof Mark Shevlin, Dr Donal McAteer, Dr Colin, Gorman, Dr Jamie Murphy (Ulster University).

Knowledge Exchange Seminar Series 2016-17

Abstract

The prevalence of mental health problems in Northern Ireland (NI) is 19%, and this is 25% higher than in England (DHSSPS, 2014). In recent years, there have been extensive consultations, and subsequent recommendations made in NI, in an effort to address this issue and to support an improved infrastructure for the training and development of those working within mental health services (DHSSPS, 2012, 2015). Reform within mental health services in NI has been informed over the past decade by the Bamford review from which two action plans have been proposed (DHSSPS, 2012, 2015). In response to this, researchers at Ulster University wanted to demonstrate an evidence base for the implementation of a new primary care/community based psychological therapies service model in NI, based on the UK ‘Improving Access to Psychological Therapies’ (IAPT) service model. This was informed by the National Institute of Clinical Excellence (NICE) guidelines, which advocates the use of low intensity cognitive behavioural therapy (LI-CBT) for mild to moderate anxiety and depression (NICE 2004a, 2004b). Evidence from IAPT sites suggest that the model is clinically effective (Clark, Layard, Smithies, Richards, Suckling & Wright, 2009) but that the appropriate resourcing of steps one and two is a more cost effective way to manage the high demands placed on health services. Hence, the current study aims to evaluate the effectiveness of implementing an IAPT service model using LI-CBT in primary and community care settings in NI. Two clinically valid routine outcome measures were used, which evaluate every client in every session, with data collection for the first phase of the study taking place between January 2015 and October 2016. Preliminary reliable change outcomes for the pilot cohorts showed recovery rates of 47.9%, improvement rates of 76.7% and deterioration rates of 6%. These findings indicate that the IAPT service model is clinically effective in a NI population. Data collection for the study is continuing between November 2016 and November 2017, using the same outcome measures, and additional follow-up data will also be examined in order to determine if the psychological benefits of interventions are maintained over time. Future analyses will also aim to identify individual and service level factors which potentially impact the effectiveness of the intervention.

Background

The English IAPT initiative

‘Improving Access to Psychological Therapies’ (IAPT) is a large scale initiative which has received substantial government investment in England (Gyani, Shafran, Layard and Clark (2013). It was first implemented in 2007, and aims to improve access to evidenced-based psychological treatments for common mental health difficulties, primarily depression and anxiety (Clark, et al, 2009). ‘Access’ specifically refers to the provision of treatments which embrace utilization, and availability, as well as efficiency and effectiveness. Furthermore, improved access is attributed to equity and to promote a culture of social inclusion and patient centeredness (Gulliford, Hughes & Figeroa-Munoz, 2001).

The IAPT service model is informed by the National Institute of Clinical Excellence (NICE) guidelines, which advocate the use of cognitive behavioural therapy (CBT) in the treatment of anxiety and depression (NICE 2004a, 2004b). Importantly, these guidelines also recommend that psychological interventions are delivered according to a stepped care framework, whereby the most effective, yet least resource-intensive, treatment is delivered first. NICE guidelines recommend that mild to moderate depression and anxiety can be managed effectively using low intensity interventions within primary care and community level settings (DHSSPS, 2005). Low intensity in this case refers to forms of CBT treatment which can be delivered in non-traditional formats (e.g. via telephone/online) and often require less practitioner support in terms of the frequency and duration of sessions. The IAPT workforce delivering these interventions are referred to as psychological wellbeing practitioners (PWP: Richards and Whyte, 2011).

Evidence from UK IAPT sites suggest that low intensity CBT is an effective treatment for mild to moderate depression and anxiety (Clark et al, 2009). Gyani, et al. (2013) examined data from 32 IAPT sites, representing approximately 19,000 clinical cases, and reported that 40% of individuals had reliably recovered and 64% had reliably improved since using the service. Within IAPT services, clients complete the PHQ-9 (measuring depression), and the GAD-7 (measuring anxiety) at each contact. Improvement is determined using a reliable change index whereby six and four indicate reliable change in depression and anxiety respectively. Recovery requires a demonstration of reliable improvement, with final scores below clinical thresholds, on both psychometric measures at the end of treatment.

The IAPT initiative has also been demonstrated to have important cost benefits. The estimated average cost for a low intensity session and course of treatment was £99 and £493 respectively. These estimates are supportive of the originally proposed IAPT programme on cost-benefit grounds (Layard, Clark, Knapp & Mayraz, 2007;

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Radhakrishnan, Hammond, Jones, Watson, McMillan-Shields, & Lafortune, 2013). The rationale for nationwide implementation has also been motivated by the potential economic gains associated with increased productivity and re-employment (Layard et al., 2007)

Mental Health Services in Northern Ireland

The prevalence of mental health problems in Northern Ireland (NI) is 19%, and this is 25% higher than in England (DHSSPS, 2014). Despite the prevalence of mental health difficulties in NI being 25% higher, services in England spend more than double the per capita spend on the provision of support for individuals with mental health difficulties (DHSSPS, 2010; DHSSPS, 2014). In recent years numerous policy documents relating to mental health services in Northern Ireland have been published to address this issue and to support an improved infrastructure for the training and development of those working in mental health services (e.g. Making Life Better 2012-2023, Northern Ireland Public Health Framework 2012; Transforming Your Care, DOH 2011; Health and Wellbeing 2026, DOH 2016). Moreover, reform of mental health services in Northern Ireland has been informed throughout the past decade by the Bamford Review (Bamford, 2006). In 2016, the Department of Health Northern Ireland initiated an evaluation of the 2009-2011 and 2012-2015 Bamford action plans (DHSSPS, 2012, 2015). Preliminary findings highlighted that there remains a need to further promote psychological therapies, to improve access to services in times of crisis, and to improve involvement at the community and voluntary level. Funding reductions are considered to account, in part, for the failure to fully implement Bamford recommendations and best practice initiatives throughout the province. (DHSSPS, 2012, 2015).

The Strategy for the development and implementation of psychological therapy services in Northern Ireland (DHSSPS, 2010) recommended that psychological therapies should be a “core component” within mental health services (pg 49). Recommendations made in regards to strategy implementation indicate that additional investment, in the region of £4.4 million, would be required annually from 2011 within psychological therapies in order to facilitate significant reform.

However, the Bamford Vision acknowledged that further funding would be required for mental health and learning disability services across a 10 to 15-year period, due to historically inadequate investments and the growing need for psychological treatment in NI. Recently reported figures indicate that none of Northern Ireland’s five Health Trusts have met the 13 week waiting time targets for treating individuals with mental health problems during the last three years, and local government already acknowledged the need for a workforce strategy to avoid potential shortfalls such as this (HSCB, 2015). From the perspective of service users and providers, a recent report from Action Mental Health indicated that service users feel they are not treated like people but as problems to be managed. From a systemic perspective, serious concerns were highlighted regarding inadequate funding, fragmentation of services, poor communication and lack of leadership (AMH, 2015).

Overuse of pharmacological interventions

It has been recently reported that that GPs in Northern Ireland prescribe anti-depressant medications at a rate 2.5 times higher than in England and Wales (McClure, 2013). Whilst not disregarding the legacy of the ‘Troubles’, prescription rates were found to be significantly higher than in other UK regions with similar economic profiles and even higher rates of depression, which again points to an issue of potentially inadequate access to non- pharmacological help. In response, and in order to provide GPs with an alternative to medications for common mental health problems, ‘Primary Care talking therapy hubs’ were introduced in NI (HSCB, 2015). The aim of such Hubs is to advocate prevention and early intervention using services including counselling, CBT, group therapy, guided self-help, life coaching and signposting to community services. Hubs in the five Health and Social Care Trusts across the province are still in the process of being established, and there has been recognition from local government that additional hubs with appropriately trained staff are required (HSCB, 2015).

Psychological Therapies in Primary Care

Although the efficacy of early interventions such as low intensity cognitive behavioural therapy (LI-CBT) is most strongly evidenced with depression and anxiety, and although such approaches are shown to save money in the long term (Layard et al., 2007), a stepped care model has not yet been fully established in NI (Blane, Williams, Morrison, Wilson and Mercer, 2014). Psychological therapy service provision in NI has tended to focus on the more complex end of the spectrum of mental health difficulties, and consequently, educational and professional training has similarly concentrated largely on individuals working at these levels. In 2013, the Northern Ireland Mental Health Services Threshold Criteria acknowledged that low intensity therapists working at stepped care

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levels one and two, including those delivering LI-CBT, are crucial for the establishment of an effective stepped care approach to psychological therapy provision in the province (MHSTC, 2013).

Training of Psychological Wellbeing Practitioners in Northern Ireland

In light of the mental health problems faced by large numbers of the population in NI, and in recognition of the need for an appropriately skilled and experienced workforce to fill the aforementioned gap in service provision, Ulster University developed accredited training in evidence-based low intensity interventions for common mental health difficulties. Since 2014, this has facilitated the training of British Psychological Society accredited Psychological Wellbeing Practitioners (PWPs), who deliver low intensity cognitive behavioural therapy interventions to individuals within Primary/Community Care level services throughout training.

Aims and Objectives

Considering the evidence presented above, it is clear that the current provision of psychological therapies at the Primary/Community Care Level in NI is in its early stages of development, with few empirical evaluations to date of the effectiveness of treatment approaches at this level. Indeed, the recent DoH (2016) indicated that the improvement of access to psychological services has been wholly inadequate and significant funding is required to match that which is being offered in England. Hence, there is a need to provide evidence of a service model that works, and can be implemented effectively in NI. The main objective of the current pilot study is to present the preliminary findings of an evaluation of PWPs providing LI-CBT for common mental health difficulties working directly with the newly established ‘Primary care Talking Therapies Hubs’ and community care settings in an NI context. It was predicted that following a course of LI-CBT there would be a reduction in PHQ-9 and GAD-7 scores to normal range below clinical thresholds, and that these findings would be in keeping with existing IAPT UK outcomes, thereby providing initial evidence that the IAPT service model is effective in a Northern Ireland context.

Method

This was a prospective study following a cohort of participants from baseline (before commencement of therapy), through the course of LI-CBT weekly treatment (1-11) sessions, and ‘follow-up’ (4 months post-discharge). This study is limited to examining changes in psychological status in participants before and after therapy; the follow- up analysis is part of an on-going project.

Sample

Trainee PWPs consisted of students on the MSc applied psychology course at Ulster University, which facilitated clinical skills, training, placements and supervision. Data from a total of 199 patients who attended a trainee PWP within the 2015 and 2016 cohorts was collected. (see figure 1). In keeping with IAPT recommendations (Gyani et al., 2013), the clinical outcomes reported here are related only to clients meeting “caseness” criteria. This required at least two contacts with a PWP as pre and post treatment scores cannot be collected based on a single initial session. A ‘case’ client must also have scored above the clinical thresholds on at least one of the measures at assessment, more specifically this refers to scores of 10 and/or 7 or above on the PHQ-9 and GAD-7 respectively. 165 clients were identified as “case” and 35 were identified as “non-case” prior to analysis, in accordance with this IAPT “caseness” criteria. Of the clients fitting caseness criteria, there were 105 females and 60 males. Ages ranged from 18 to 77, with a mean age of 39. 55% of patients were treated in community settings, 18% in a GP practice, and 27% at primary care services psychological therapies within a Northern Ireland NHS Trust.

Measures

As per IAPT service protocol, each client at each contact completed two routine outcome measures.

The Patient Health Questionnaire (PHQ-9) was used to measure the severity of depressive symptoms. This is a nine-item standardised measure which has been validated in a UK depressed population (Cameron, Crawford, Lawton & Reid, 2008). The scores range from 0 to 27, with a score of ten or more being the threshold to identify clinically relevant depressive symptoms (Kroneke, Spitzer & Williams, 2001).

The General Anxiety Disorder Questionnaire (GAD-7) has also been determined to have good psychometric properties having been validated in U.S. populations. The scores range from 0 to 21 and a score of eight or more

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being the threshold to identify clinically relevant general anxiety disorder (Kroneke, Spitzer, Williams, Monahan & Lowe, 2007).

Trainee PWPs consisted of students on the MSc applied psychology course at Ulster University, which facilitated clinical skills, training, placements and supervision. Data from a total of 199 patients who attended a trainee PWP within the 2015 and 2016 cohorts was collected. In keeping with IAPT recommendations (Gyani et al., 2013), the clinical outcomes reported here are related only to clients meeting “caseness” criteria. This required at least two contacts with a PWP as pre and post treatment scores cannot be collected based on a single initial session.

A ‘case’ client must also have scored above the clinical thresholds on at least one of the measures at assessment; more specifically, this refers to scores of 10 or above on the PHQ-9 and/or 8 or above on the GAD-7. 165 clients were identified as “case” and 34 were identified as “non-case” prior to analysis, in accordance with the IAPT “caseness” criteria. Of the clients fitting caseness criteria, there were 105 females and 60 males. Ages ranged from 18 to 77, with a mean age of 39. 55% of patients were treated in community settings, 18% in a GP practice, and 27% at primary care psychological therapies service within a Northern Ireland NHS Trust.

Reliable change rates

The Reliable Change Index (Jacobson & Truax, 1991) is an appropriate way of assessing deterioration or improvement in anxiety and depression symptoms, as it allows one to determine whether an increase or decrease in psychometric scores from baseline to post-treatment exceeds the measurement error of the relevant scale, and thereby can be considered statistically reliable. In keeping with existing IAPT evaluations (Gyani et al., 2013), a reduction or increase of six or more points on the PHQ-9 and a reduction or increase of four or more points on the GAD-7 have been determined as the thresholds for reliable change in depression and anxiety symptoms respectively. Clients are considered to have ‘reliably improved’ if either of their measure scores reliably decreased and the score for the other measure either remained the same or did not reliably deteriorate. Clients are considered to have ‘reliably deteriorated’ if either measure score reliably increased, or the other score either also increased or did not reliably improve. A reliable recovery index was also used in line with existing IAPT studies (Gyani et al., 2013). Clients are considered to be ‘reliably recovered’ if they scored above the clinical threshold on at least one psychometric measure at assessment interview, showed reliable improvement during the course of treatment, and scored below clinical thresholds on both the PHQ-9 and GAD-7 at the point of treatment completion. For example:

  •   A case client with the following scores would have demonstrated reliable improvement: baseline PHQ-9 (13), baseline GAD-7 (9), final PHQ-9 (7), final GAD-7 (8).

  •   A case client with the following scores would have demonstrated reliable deterioration: baseline PHQ-9 (14), baseline GAD-7 (10), final PHQ-9 (9), final GAD-7 (14).

  •   A case client with the following scores would have demonstrated reliable recovery: baseline PHQ-9 (15), baseline GAD-7 (8), final PHQ-9 (8), final GAD-7 (5)

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Results

A total of 199 participants sought access to the service. Of these, 198 were assessed and of these 178 attended a second session at least; the rate of uptake of LICBT was therefore 89.4%. Overall, 47.9% of patients who met caseness criteria demonstrated reliable recovery. 76.7% of these patients demonstrated reliable improvement, and 6.1% demonstrated reliable deterioration (see table 1).

Table 1: Frequencies and percentages of reliable recovery, improvement and deterioration rates for LICBT patients meeting caseness criteria for cohorts 2014/15 and 2015/16.

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*Caseness criteria met (n= 165)

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Yes
No Missing

Reliable Improvement demonstrated

125 (77%) 38 (23%) 2 (1.2%)

Reliable Deterioration demonstrated

10 (6%) 153 (94%) 2 (1.2%)

Reliable Recovery demonstrated

78 (48%) 85 (52%) 2 (1.2%)

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*At least 2 sessions attended and above clinical thresholds on one or both measures at baseline = caseness

Discussion

Initial Northern Ireland outcomes: Clinical effectiveness

Findings from the current study are in keeping with outcomes from UK IAPT sites including the previously reported 2015/16 outcomes (HSC, 2016). More specifically, when NI reliable change rates are compared directly with the most recently published IAPT UK outcomes, recovery rates are 47.9% and 46.3% respectively. Improvement rates are 76.7% and 62.2% for NI and England respectively (HSC, 2016). These preliminary results provide initial evidence that low intensity cognitive behavioural therapy is an effective treatment for mild to moderate level mental health difficulties in NI. As reported earlier the prevalence of mental difficulties in NI is 25% higher than in England (DHSSPS, 2014). More explicitly, the Northern Ireland Health Survey (2014/15) reported that 19% of respondents exhibited symptoms of a potential mental health problem (Bell & Scarlett, 2015). Assuming this population was suitable for LI-CBT, it may be estimated based on the current findings that prevalence could be reduced to 4.4% with reference to improvement rates and 9.9% with reference to recovery rates.

Cost benefits: increasing reemployment and productivity

Furthermore, research also indicates that 22% of individuals in NI live in poverty (Bell & Scarlet, 2015). Indeed, in Northern Ireland, the prevalence of mental health difficulties is doubled (30%) for those in the most deprived areas, when compared with those in areas of less deprivation (15%) (Bell & Scarlett, 2015). It is estimated that recent public cuts have affected Northern Ireland in a particularly detrimental way, given that the region relies on public spending for 62.2% of its output, compared to 39.8% in the rest of the UK.

Compared with other regions of the UK, NI has the highest proportion of adults not in work (28.4%). More precisely, this is 5% higher than the UK average (O’Neill, McGregor & Merkur, 2012). Absenteeism is heavily attributed to mental health difficulties, more specifically accounting for 31.9% of all lost days, and 39.1% of long- term sick leave (NISRA, 2015). The economic gains directly associated with IAPT in England in the first three years include almost 45,000 individuals moving off benefits (Clark, 2011). As the IAPT model has been applied to mental health clients in the current study, the LI-CBT interventions used here could have a similar impact on individuals moving off benefits and returning to work in NI. The findings of the current study can therefore be

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tentatively applied to infer that such evidence based interventions for common mental health problems could reduce rates of absenteeism in the province. Using the NISRA figures, days lost through mental health issues could therefore be reduced to 7.43% as per improvement rates found in the current study, and 16.7% as per recovery rates. However, this would need to be formally evaluated, and hence our future research recommendations are to assess prospective employment/benefit rates for the 2016/2017 cohort.

Further expansion of the English IAPT initiative has been recommended as a step to achieving better access to mental health services by 2020 (DOH, 2014). Investment in health care is important for both socioeconomic and ethical reasons, but has also been emphasised in order to counteract perceived “institutional bias”. More resources are dedicated to physical healthcare even though mental ill health can accrue an annual societal cost of up to 100 billion (DOH, 2014).

Moreover, Layard and Clark (2015) have recently reported on reasons why more psychological therapy would cost nothing. In the majority of wealthy countries, approximately 1% of the working age population are on benefits due to depression or anxiety. This costs the UK government £650 more per month per person, compared with if they were not receiving these payments. If a minimum of just 4% of this patient population worked for just one more month following treatment, the actual cost of treatment would be fully repaid. The argument to expand service provision is therefore thoroughly justified.

Adhering to the evidence base: Delivering the right treatment, at the right time, in the right place

As outlined earlier, the IAPT service model is informed by evidence based clinical guidelines. Our findings support these NICE guidelines in a NI context, which advocate the use of cognitive behavioural therapy for depression and anxiety. NICE assemble a panel of experts made up of clinicians, researchers and consumers who carefully review the available evidence base on the optimum treatments for each physical and mental health problem. In 2004, NICE carried out systematic reviews of research investigating the effectiveness of interventions for depression and anxiety disorders. The resultant clinical guidelines advocate the provision of specific kinds of cognitive behavioural therapy (CBT) for depression and anxiety disorders (NICE, 2004). Crucially, cognitive behavioural therapy is considered to be more effective than medication given that it reduces the likelihood of relapse by at least 50%, and moreover, the vast majority of patients prefer it to a psychological treatment (McHugh, Whitton, Peckham, Welge and Otto, 2013).

As previously outlined, NICE guidelines further recommend that mild to moderate depression and anxiety can be managed effectively using low intensity interventions within primary care level settings (DSSPS, 2005). Furthermore, low intensity interventions improve the flexibility, capacity and responsiveness of the relevant services while increasing patient-choice, and enhancing service cost-effectiveness (Bennett-Levy et al., 2012).

Conclusion

Currently, the mental health service framework in NI does not formally apply this NICE evidence, which has also been highlighted in the recent Evaluation of the Bamford Action Plans (DoH, 2016). Our findings indicate that reliable recovery and improvement have been demonstrated for clients in NI who have presented with common mental health difficulties. Indeed, LI-CBT interventions (provided by PWPs) provides the only evidence base to date in NI for treating anxiety and depression at stepped care levels 1-3. Additionally, the Bamford evaluation highlighted a need to further promote psychological therapies, to improve access to services in times of crisis, and to improve involvement at the community and voluntary level (DOH, 2016; Betts &Thompson, 2017). Our initial findings indicate that PWP’s have addressed this need.

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Recommendations and plans for future low intensity CBT research in Northern Ireland

Clinical Policy Recommendations:

  •   Whilst the findings of this study are preliminary, the current pilot offers a potential solution to addressing the need for evidence-based treatment and suggests that low intensity CBT (provided by accredited PWPs), is a clinical and cost-effective intervention, as well as being an effective service model within primary and community care settings in NI (stepped care 1-3).

  •   Therefore, our recommendation to practice and policy implementation, is that in order to assist the people of NI to gain access to appropriate, clinical and cost effective psychological interventions at steps 1-3, a province-wide PWP service (embedded within the talking therapy hubs and GP practices) needs to be fully established and adequately funded. This could potentially prevent more complex mental health issues through the use of early intervention and quicker access to services with reduced waiting times, and by enabling service users to access the right treatment in the right place at the right time.

  •   Indeed, some recent recommendations made by Sands (2017) have suggested the placing of mental health practitioners, offering the appropriate level of CBT, in every GP practice in NI. We are suggesting that PWP’s can be that ‘mental health practitioner’, who are fit for purpose and fit for the future of NI mental health services.

    Research recommendations:

  •   The collection of patient data and routine outcome measures is continuing at pre-treatment, post treatment and follow up points. In this study future analyses will focus on this larger sample of all previous, current and future cohorts combined. Reliable recovery, improvement and deterioration rates will be produced.

  •   Previous IAPT studies have determined that many of the psychological benefits resulting from interventions had been maintained (Clark et al., 2009). In order to produce comparative data regarding longer-term effectiveness, future N. Ireland research will also examine data collected from clients at a four month follow-up point after discharge from the service.

  •   In order to test for individual differences in treatment effect, a series of latent growth curve models will be specified and tested in order to determine if there are different rates of change for unobservable sub- populations, and to identify individual or service level variables which potentially increase or reduce the effectiveness of the intervention.

  •   Furthermore, data on employment statuses and medication usage pre and post treatment will be scrutinised. Increasingly, governments are driven by the recognition of the huge economic and social costs of high prevalence disorders, and so we need future research to evaluate cost effectiveness in order to inform future service design and planning. Randomised controlled trials facilitating a comparison of service models may also provide further evidence for the effectiveness of the IAPT model in a Northern Ireland context.

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References

Bamford, D. (2006). The Bamford review of mental health and learning disability (Northern Ireland).

Bell, C., & Scarlett, M. (2015). Health Survey Northern Ireland: First Results 2014/15.

Bennett-Levy, J. E., Butler, G. E., Fennell, M. E., Hackman, A. E., Mueller, M. E., & Westbrook, D. E. (2004). Oxford guide to behavioural experiments in cognitive therapy. Oxford University Press.

Betts, J and Thompson, J (2017). Mental Health in Northern Ireland: Overview, Strategies, Policies, Care Pathways, CAMHS and Barriers to Accessing Services. Research and Information Service Research Paper. Northern Ireland Assembly.

Blane, D. N., Williams, C., Morrison, J., Wilson, A., & Mercer, S. (2014). Psychological therapies in primary care: a progress report.

Cameron, I. M., Crawford, J. R., Lawton, K., & Reid, I. C. (2008). Psychometric comparison of PHQ-9 and HADS for measuring depression severity in primary care. Br J Gen Pract, 58(546), 32-36.

Clark, D. M. (2011). Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: the IAPT experience. International Review of Psychiatry, 23(4), 318-327.

Clark, D. M., Layard, R., Smithies, R., Richards, D. A., Suckling, R., & Wright, B. (2009). Improving access to psychological therapy: Initial evaluation of two UK demonstration sites. Behaviour research and therapy, 47(11), 910-920.

Department of Health and NHS (2014). Achieving Better Access to Mental Health Services by 2020. Department of Health Social Sciences and Public Safety (2014). Bamford monitoring report.

Department of Health Social Sciences and Public Safety (2015) Delivering the Bamford vision: The Response of the Northern Ireland Executive to the Bamford review of Mental Health and Disability Action Plan 2012-2015.

Department of Health Social Sciences and Public Safety: Integrated Projects Unit (2012) Evaluation of the Bamford action plan.

Department of Health SS, AND Public Safety. IAPT outline specification: Improving Access To Psychological Therapies (IAPT) 2005.

Department of Health, Social Services and Public Safety. A strategy for the development of psychological therapies services. Northern Ireland: Department of Health Social Services and Public Safety (2010).

Department of Health, Social Services and Public Safety. Making Life Better: A whole system strategic framework for public health 2013-2023. Department of Health, social Services and Public Safety: Belfast. (2014).

Department of Health, Social Services and Public Safety. Reshaping the System: Implications for Norther Ireland’s Health and Social Care Services of the 2010 Spending Review (McKinsey Report). Belfast: Belfast. (2010).

Gulliford, M., Hughes, D., Figeroa-Munoz, J., & Guy’s, King’s and St Thomas’ School of Medicine, London (United Kingdom). Public Health and Health Services Research Group;. (2001). Access to Health Care: Report of a Scoping Exercise for the National Co-ordinating Centre for NHS Service Delivery and Organisation R and D (NCCSDO) 26 February 2001 (with Minor Amendments August 2001). Guy’s, King’s and St Thomas’ School of Medicine, Public Health and Health Services Research Group.

Gyani, A., Shafran, R., Layard, R., & Clark, D. M. (2013). Enhancing recovery rates: lessons from year one of IAPT. Behaviour Research and Therapy, 51(9), 597-606.

Health and Social Care Board (2014) You In Mind. Mental Healthcare Pathway.
Health and Social Care Board (2015). Introducing Primary Care Talking Therapy and Well-being Hubs.

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Health and Social Care Information Centre (2016), Psychological Therapies, Annual Report on the use of IPAT services.

Jacobson, N. S., & Truax, P. (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of consulting and clinical psychology, 59(1), 12.

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The Phq‐9. Journal of general internal medicine, 16(9), 606- 613.

Kroenke, K., Spitzer, R. L., Williams, J. B., Monahan, P. O., & Lö we, B. (2007). Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Annals of internal medicine, 146(5), 317-325.

Layard, R., Clark, D., Knapp, M., & Mayraz, G. (2007). Annex D: Cost-benefit analysis of psychological therapy. Department of health Improving Access to Psychological Therapies (IAPT) programme: An outline business case for the national rollout of local psychological therapy services. London: Department of Health.

Layard, R., & Clark, D. M. (2015). Why more psychological therapy would cost nothing. Frontiers in psychology, 6, 1713.

McHugh, R. K., Whitton, S. W., Peckham, A. D., Welge, J. A., & Otto, M. W. (2013). Patient preference for psychological vs. pharmacological treatment of psychiatric disorders: a meta-analytic review. The Journal of clinical psychiatry, 74(6), 595.

National Audit Office (NAO). Healthcare across the UK: a comparison of the NHS in England, Scotland, Wales and Northern Ireland. London: TSO. (2012-2013).

National Institute for Clinical Excellence, & Britain, G. (2004). Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. National Institute for Clinical Excellence.

National Collaborating Centre for Mental Health. (2004). Depression: management of depression in primary and secondary care. London: National Institute for Clinical Excellence.

NISRA (2015). Sickness absence in the Northern Ireland Civil Service 2014/15. Department of Finance and Personnel. Belfast.

O’Neill,C, McGregor, P., & Merkur, S. (2012). United Kingdom (Northern Ireland). Health System Review. Health Systems in Transition, 14(10).

Radhakrishnan, M., Hammond, G., Jones, P. B., Watson, A., McMillan-Shields, F., & Lafortune, L. (2013). Cost of improving Access to Psychological Therapies (IAPT) programme: an analysis of cost of session, treatment and recovery in selected Primary Care Trusts in the East of England region. Behaviour research and therapy, 51(1), 37-45.

Richards DA, Whyte M. Reach Out: National programme student materials to support the training and for Psychological Wellbeing Practitioners delivering low intensity interventions. UK: Rethink Mental Illness, 2011.

Sands, Louise (2017). RCGP Associate Director – Policy Reform seminar on improving mental health provision in NI, 17th Jan 2017), as cited in Betts, J and Thompson, J (2017). Mental Health in Northern Ireland: Overview, Strategies, Policies, Care Pathways, CAMHS and Barriers to Accessing Services. Research and Information Service Research Paper. Northern Ireland Assembly

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The Damaging Consequences of Not Offering The Best Mental Health Treatment Initially

many will vote with their feet when it comes to further treatment from the same source. Stepped care is the treatment model adopted by the UK Government’s Improving Access to Psychological Therapies (IAPT) Programme. A third (34%) of those who have low intensity therapy are stepped up to high intensity city, according to the IAPT Manual 2021, but the Manual cautions there is considerable local variation in this figure. The question is why? This does not sound like clients following well-defined pathways. As far as I can ascertain IAPT does not publish a recovery rate from low intensity alone, so it is not known what proportion haemorrhage from low intensity.  IAPT is the only show in Town for most people so it is not surprising that when treatment fails some return. For every 2 people referred to IAPT 1 person is attending for between their second and tenth plus courses of treatment – a revolving door. [Following a Freedom of Information Request from Dr Elisabeth Cotton in 2018, it appears that 1.5 million people were referred to IAPT between 2 and 10 or more occasions in a 6 year period (2012-2018), with 3.2 million people referred just once].

 

 

What is going on here? NHS England is replete with the following luminaries according to the IAPT Manual (2021), so it is no surprise that there has been no publicly funded independent audit of the Service:

Current NHS England team

Sarah Holloway, Head of Mental Health, NHS England
Xanthe Townend, Programme Lead – IAPT & Dementia, NHS England

David M. Clark, Professor and Chair of Experimental Psychology, University of Oxford; National Clinical and Informatics Adviser for IAPT

Adrian Whittington, National Lead for Psychological Professions, NHSE/I and HEE; IAPT National Clinical Advisor: Education

Jullie Tran Graham, Senior IAPT Programme Manager
Hayley Matthews, IAPT Programme Manager, NHS England Andrew Armitage, IAPT Senior Project Manager, NHS England Sarah Wood, IAPT Project Manager, NHS England

 It appears common sense for IAPT to offer the least costly service first e.g computer assisted therapy and then progress clients to the more costly face to face service if the minimalist intervention has not worked. But IAPT have borrowed from medical care a modus operandi that is not fit for purpose in mental health. For example there is evidence that for some with back pain, physiotherapy will resolve  problems and is the sensible first line treatment, with progression to the costly surgical interventions if physiotherapy does not suffice. But low intensity psychological therapy does not have the evidence base of physiotherapy. This opens up the likelihood that LI will fail to return the client to their best functioning.  Approx a third of clients (37%) receive low intensity only and a third (29%) high intensity only.

 

The mental health clients take on a failed  first line treatment is likely to involve personalisation e.g  ‘I am stupid, couldn’t quite get what was being asked to do’ and arbitrary inferences e.g ‘I shouldn’t have expected anything would work with me, just my luck’. This is quite different to how most people would likely respond to a failed first line physical intervention. For mental health treatment it may be the the best treatment should be provided first. At a minimum clients should be informed that they are consenting to what is known to be second best.

 

Dr Mike Scott

 

Decrypting the Improving Access to Psychological Therapies (IAPT) Code

IAPT communications have an agenda, their focus is on persuading their source of revenue, local Clinical Commissioning Groups (CCGs) to expand funding, to cover staffing costs of £0.5billion by 2024.  To achieve this goal it uses language that is familiar to the GPs that comprise CCGs, ‘NICE compliant’, ‘recovery’ and claiming a comparability of outcome to those in randomised controlled trials. But CCG’s are themselves under orders from NHS England, who have never critically appraised IAPT’s claims.

The secret to breaking the IAPT Code, is strangely its’ use of the ICD-10 code (the World Health Organisation’s labelling system for all disorders). The recent IAPT Manual (August 2021) https://www.england.nhs.uk/wp-content/uploads/2018/06/the-iapt-manual-v5.pdf recommends that IAPT clinicians give at least one code to each client, to characterise their debility. But nowhere in the Manual does it suggest that IAPT clinicians make a diagnosis. An ICD-10 code is only as reliable as the diagnosis made. The Manual claims that NICE Guidelines are based on ICD-10 codes and that IAPT is therefore NICE compliant.  However the treatments recommended by NICE are all diagnosis specific, it follows that if there is no diagnosis there can be no fidelity to a NICE protocol. A key part of IAPT’s code is to gloss over that IAPT’s interventions are based, not on diagnosis but on ‘problem descriptors’. The silent assumptions are that:

a) there would be reliable agreement (reliability) between clinicians about what would constitute a clients main problem and

b) there is a body of evidence that a problem descriptor acts as a key to unlock the door to a specific protocol. Further that the specific protocol has been demonstrated to confer an added value, over and above an active placebo, for the chosen problem descriptor. There is an assumption of clinical utility.

But there is no empirical evidence for either a) the reliability or b) the clinical utility. 

IAPT operates its’ own coding device, akin to the Enigma machine used by the Germans in World War 2, and it has as a result ill-served millions. NHS England and CCG’s have totally failed to recognise its’ operation, believing instead IAPT’s public broadcasts e.g a 50% recovery rate, when independent assessment indicates a 10% recovery rate Scott (2018) https://doi.org/10.1177%2F1359105318755264.

Dr Mike Scott