Clinical Commissioning Groups Decade of Neglect In Auditing Mental Health Pathway

no Clinical Commissioning Group has been compliant with NICE’s (2011) 1.5.1.2 https://www.nice.org.uk/guidance/cg123 injunction for them to audit and review local mental health pathways. Instead, the  CCGs have left it to the Improving Access to Psychological Therapies (IAPT) programme to mark their own homework. NHS England has turned a blind eye. Can there be a better example of institutionalised bias against mental health patients?

The National Institute for Health and Clinical Excellence (NICE) document https://www.nice.org.uk/guidance/cg123 (2011) also advocates a stepped care model that ‘provides the least intrusive  and most effective intervention first’. But this creates a conundrum in that, clearly the least intrusive interventions include, guided self-help, computerised CBT and psychoeducation groups, what would be deemed low intensity interventions in IAPT. However, the NICE recommended treatments for specific disorders, are recommended in a dosage that would be incompatible with a low intensity intervention. It is only the high dosage interventions that have been credibly systematically evaluated in randomised controlled trials. Contrary to the assertion of Boyd et al (2019) https://doi.org/10.1371/journal.pone.0214715 there is not ‘sound evidence for the efficacy of low intensity interventions’.  The methodological quality of the studies that form the basis for NICE’s recommendation for specific disorder treatments is much stronger than the foundation for the low intensity recommendations. Thus to provide ‘the most effective intervention’ first would mean jettisoning low intensity interventions and herald the demise of the stepped care model!

The mnemonic PICOT has been advocated by NHS England (2013) Finding the Evidence https://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwj5_-fAhbn0AhXDiVwKHSgdDnYQFnoECBgQAQ&url=https%3A%2F%2Fwww.england.nhs.uk%2Fwp-content%2Fuploads%2F2017%2F02%2Ftis-guide-finding-the-evidence-07nov.pdf&usg=AOvVaw3-7g7wSw9WFJhtWaS-gBdX to help clinicians distinguish what is an evidence-based treatment and  what is not. The P refers to the  patient/problem/population studied, I the intervention/exposure of interest, C the comparison condition, O for outcome and T the time frame. The low intensity interventions fall at each hurdle. With regards  to P the patient population is poorly specified, with reliance on a self-report measure rather than a ‘gold standard’ diagnostic interview. The intervention used, I, is fuzzier in low intensity interventions with no indication as to how it is adapted to the needs of the individual. The comparison conditions, C are invariably waiting list controls in low intensity interventions, but patients on waiting lists do not expect to get better, the appropriate comparison is an active control group e.g attendance at a shyness group to learn from each other what works best for them. The outcome, 0, in low intensity interventions is always a change on a self-report measure, it is never complemented by an independent evaluation of the diagnostic status of the person. Finally T, there is no indication in the low intensity studies of the duration of gains i.e what proportion of those who have recovered go on to maintain their gains. Whilst not all rct’s of  high intensity interventions clear the PICOT hurdles about half do and these interventions merit a strong recommendation. These studies are qualitatively different to the low intensity studies.

 

 

It is a source of concern that the manufacturers of Silver Cloud, a computerised CBT programme, is the sponsor of a recently publicised IAPT training day. 

 

Dr Mike Scott

 

No Evidence That The Improving Access to Psychological Therapies (IAPT) Service Does Any Better Than Contact With The Citizen’s Advice Bureaux (CABx)

 

IAPT claims 50% of its treated clients recover. But this effectiveness claim refers to the minority sub-population, who attend two or more treatment sessions. There is a deafening silence about the majority and that IAPT has marked its’ own homework. By contrast the CABx reports results for all-comers and as assessed by independent researchers.  In its’ latest report the CABx states that the proportion of people who reported improved mental health as a result of contact was 70% in the last quarter of 2020/2021.

In the CABx population almost 80% of clients said that their problems made them feel stressed or anxious and over 60% said they had difficulty in getting on with daily life. With just over 20% of CABx clients stating that contact had helped them a great deal to get on with their life, and just less than 20% saying that contact helped a little and 20% saying that it helped somewhat..The latest CABx report  states that this year they carried out ‘robust client follow up research. National Outcomes and Impact Research (NOIR). This asked detailed questions about why people came to us for advice, what their problems were and how we helped’. NOIR research was conducted over the telephone with a nationally representative sample of clients. The NOIR asked 60,000 clients about their experience of CABX in the last year. THE CABx research was funded by the National Institute for Health Research.  

In 2020-2021 the CABx saw 58,000 people face to face, with 624,000 receiving help by email or webchat and 1.48 million people using the CABx phone service.  The throughput of clients in CABx is about double that of IAPT.

It can be objected that IAPT population is more ‘complex’ than the CABx but the diagnostic status of neither population has been assed by a gold standard diagnostic interview. The burden of proof is on IAPT to demonstrate more ‘complexity’ and that it is especially equipped to treat such complexity. The CABx also provides a Gambling Support Service, it screened 19,000 clients and found 5% at risk of harm from gambling. Gambling was not a problem descriptor used by any of the IAPT therapists in the Saunders et al study. In both the CABx and IAPT populations (Davis et al (2020) populations 1 in 2 people are unemployed.

In 2020/21, for every £1 invested in Citizens Advice they generated:

£1.94 in savings to government and public services (fiscal benefits). By helping stop problems occurring or escalating, we reduce pressure on public services like health, housing or out-of-work benefits.

£13.36 in wider economic and social benefits (public value). Solving problems improves lives and this means better wellbeing, participation and productivity for the people we help.

£8.35 in value to people we help (financial outcomes following advice). As part of our advice we can increase people’s income, through debts written-off, taking up benefits and solving consumer problems.

To my knowledge there are no comparable figures for IAPT.

The value for money of CABx is readily apparent, it is much less obvious with IAPT.

 

Dr Mike Scott

IAPT and NICE Compliance – panic disorder a case study in infidelity

the infidelity starts with IAPT’s emphasis on psychometric tests to determine treatment. NICE (2020) http://pathways.nice.org.uk/pathways/panic-disorder, observes there are no appropriate screening instruments for panic disorder. The guidelines highlights the importance of a) detailing a timeline for the emergence of various symptoms and b) clinicians being aware of the common comorbidities of depression and substance abuse. But it is doubtful that this can be done within the typically 30 mins IAPT telephone triage assessment by Psychological Wellbeing Practitioners, the least well qualified of all IAPT staff. NICE suggests the monitoring of the frequency and severity of attacks as an outcome measure. But in IAPT notes I have never seen this systematically recorded. 

IAPT is non-compliant with NICE recommended dosages:

  1. Low intensity treatment is likely as the first step in panic disorder treatment. NICE recommends that brief CBT be around 7 hours and integrated with structured self-help materials. But Saunders et al (2021) Journal of Affective Disorders 294 (2021) 85-93 found that the average client in the Improving Access to Psychological Therapies  (IAPT) low intensity therapy has 3 sessions ( a mean of 2.85 sd 2.81). Thus over 84% of those in low intensity CBT receive less than the than the number of NICE recommended treatment  sessions for brief CBT.  But Shafran et al (2021) https://doi.org/10.1016/j.brat.2021.103803 have defined low intensity treatment as consisting of 6 hours or less therapist contact. Thus IAPT’s low intensity therapy is of such low dosage that it would not qualify for NICE’s brief CBT. 
  2. For high intensity treatment NICE recommends 7-14 hours of treatment, involving weekly sessions of 1-2 hours and completed within 4 months. But IAPT clients in high intensity treatment typically receive 5 sessions Saunders et al (2021) Journal of Affective Disorders 294 (2021) 85-93 ( a  mean 4.79 sd 5.51)]. 

IAPT has never systematically monitored compliance to NICE protocols. There is no evidence that IAPT has obeyed NICE’s guidance that ‘CBT should be delivered only by suitably trained and supervised people who can demonstrate that they adhere closely to empirically grounded treatment protocols’.

IAPT pays lip service to adherence to NICE protocols for funding purposes. But this is unacceptable, the NICE guidance is important, for example it warns that benzodiazepines are an inappropriate treatment for panic disorder. The NICE guidance is a means of challenging not only the inappropriateness of pharmacological treatment but also of psychological therapy. 

 

Dr Mike Scott

Fundamentalism and The Improving Access To Psychological Therapies (IAPT) Service

The IAPT Service is a fundamentalist translation of evidence-based psychological therapy. ‘The power of evidence-based psychological treatment’ is the sub-title of the book ‘Thrive’ by Layard and Clark (2014,) the prime movers in the development of IAPT. Whilst acknowledging the potency of evidence-based psychological treatment, it is disingenuous of IAPT fellow-travellers to muddy the distinction between the latter and the IAPT service. IAPT is like a guest at a ball, masquerading as evidence-based psychological treatment. But the hosts: politicians, NHS England and Clinical Commissioning Groups consider it impolite to make detailed enquiry of the guest, they enjoy the company. Further the National Audit Office cares not that, the ‘ball’ costs £1 bilion this year. 

The important differences between the IAPT service and the psychological therapies delivered in randomised controlled trials are apparent in the extract from Table 1 Shafran et al (2021) https://doi.org/10.1016/j.brat.2021.103803 summarised below:

A comparison of low intensity CBT and brief traditional CBT

 

 

‘Low Intensity’CBT

Brief Traditional ‘High Intensity’ CBT

Who – is it suitable for?

 

Widely used to address anxiety and depression across the age range and behavioural problems in children (e.g., Bennett et al., 2019; Cuijpers et al., 2010). Evidence supports its use for cases of all severity (Bower et al., 2013; Karyotaki et al., 2018). Typically not advocated where there are significant risk issues.

 

Typically used widely for disorders where longer traditional CBT would be appropriate

What – is delivered?

 

Interventions are based on the principles of generic CBT to enable individuals to learn specific techniques (for example graded exposure, cognitive restructuring, problem solving) with the goal of alleviating emotional distress and improving functioning. Between-session reading and excercises are central.

 

Intervention is an abbreviated version of full CBT, supplemented with provision of between session materials and excercises.

 

How long is the therapy?

Any input is typically 6 hours or less of contact, often delivered in 20-30 minute sessions

Therapy contact time is typically 50% or less than the full CBT intervention, usually delivered in 50-60 minute sessions

 

It is implicitly assumed by the advocates of IAPT that the identified differences in Table 1 do not matter. But they provide no evidence for this. The IAPT powerholders declare how therapy is to be delivered, in the absence of independent evidence of effectiveness. It represents the operation and implementation of a fundamentalist translation of the randomised controlled trials of primarily CBT for depression and the anxiety disorders. In keeping with a fundamentalist zeitgeist there is no open debate within IAPT or BABCP of the evidence for the effectiveness of the ‘alleged CBT’ in routine practice.

IAPT claims that it obtains results comparable to those achieved in rct’s but is this credible when in high intensity therapy ‘Therapy contact time is typically 50% or less than the full CBT intervention’ according to Table1? Is it credible that the organisers of the rct’s made the treatments they examined more than twice the length that was necessary? If this was indeed the case, the luminaries responsible for the trials would have been sanctioned by their funding bodies and their ability to attract further research funds, severely curtailed. The more plausible hypothesis is that IAPT does not in fact deliver evidence-based psychological treatment This despite its’ claim to do so to appease NICE, whose seal of approval is the gateway to funding..IAPT muddies the distinction between the power of evidence-based psychological treatment and the power of its’ service. 

Table 1 specifies that ‘low intensity CBT’ consists of ‘generic CBT’ but there has never been an rct of ‘generic CBT’, the rcts are of diagnosis specific protociols. Low intensity CBT cannot be regarded as an evidence-based treatment. Nevertheless, Shafran et al (2021) claim that low intensity CBT is evidence-based but inspection of the cited references reveal a different picture.

  1. The study by Karyotaki et al (2018) https://doi.org/10.1016/j.cpr.2018.06.007 is an analysis guided internet-based interventions for depression compared to control groups, with respective remission rates of 38.51% and 21.5%. But patients in the predominantly waiting list control groups do not expect to get better, so that any differences may reflect a placebo effect. There were no active control groups with a credible rationale. The studies did not involve blind assessors and there was no determination of diagnostic status at the start or end of treatment. Patients chose to enter the study online and there could be no certainty that they were representative of depressed patients in general. The mean Beck Depression inventory score at entry to the internet studies 19.4, was almost a standard deviation down on mean scores of about 27 in established rcts [Scott and Stradling (1991)]. It is doubtful that the studies reviewed by Karyotaki et al (2018) provide any evidence that this low intensity CBT makes a real-world difference to clients lives.
  2. The study by Bower et al (2013) https://doi.org/10.1136/bmj.f540 focused on whether the initial severity of depression influenced the effectiveness of low intensity interventions. As such it is not germane to the question of whether low intensity CBT is an evidence based treatment, however it cites the Cuijpers et al 2010 study doi:10.1017/S0033291710000772 as demonstrating the effectiveness of the latter. This study is also cited by Shafran et al (2021) in Table 1. In the Cuijpers et al (2010) study guided self help was compared with face to face therapy, but both treatments were determined largely by the results of a diagnostic interview (15 out of 21 studies), so that the intervention matched the diagnosis. No such diagnostic interview is conducted in either low or hight intensity IAPT.  The IAPT service has once again performed its’ own translation of the results of randomised controlled trials. Further in the Cuijpers et al (2010) review  the majority of the studies, 17 out of 21 involved media recruited clients, making the study of doubtful relevance to routine practice. In none of the studies was outcome assessed by a diagnostic interview involving a blind assessor. 

The clinical case for low intensity CBT has not been made, it is simply a short term economic convenience.Evidence that being stepped up to high intensity therapy makes a real-world difference is lacking.

 

Dr  Mike Scott

It’s A Myth That The Improving Access to Psychological Therapies (IAPT) Service Pays for Itself

IAPT has flourished over the last decade by proclaiming that it pays for itself [see Layard and Clark’s book Thrive  (2014)]. It has been music to the ears of politicians, NHS England and Clinical Commissioning Groups  but none, including the National Audit Office, has bothered to question it. Despite the £1bn price tag this year, see footnote 1. Anyone with the temerity to raise doubts, risks being accused of lacking a commitment to mental health, a pre-requisite of being considered progressive, whatever one’s political hue. 

 

When will the funding and professional bodies such as the British Psychological Society (BPS) and British Association for Behavioural and Cognitive Psychotherapy (BABCP) see that the ‘Emperor Has No Clothes’? IAPT claims the service pays for itself by getting people off unemployment benefit (16.8% of IAPT clients) Davis et al (2020) http://dx.doi.org/10.1136  and/or long term sick or disabled benefit (6.9% of IAPT clients).   It is therefore a change in the employment status of minority of IAPT clients that may justify the belief that the service pays for itself. But further elaboration of this population shows that the proportion of clients who could make an economic difference is smaller still. Further when the psychological mechanism by which a change of occupational status may operate is considered, it is improbable that the service pays for itself.  

 IAPT could in principle get 20-25% of clients off benefits. Assuming the target clientele this year is 20%, i.e 0.3 million people, how would the service pay for itself?  Well 40% of IAPT clients do not attend their 1st treatment appointment, so only 0.18 million will be exposed to an IAPT treatment therapist. Of these 42% attend just one treatment appointment, thus 0.1044 million have exposure  to IAPTs treatments and are in the categories of unemployed or long term sick, and potentially might have their employment status changed by the Service i.e 104,440. Those undergoing IAPT treatment ( defined by the Service as attending 2 or more treatment sessions) have an average of 8 treatment sessions in 2018-2019 Saunders et al (2020) https://doi.org/10.1017/S1754470X20000173 but the unemployed and those on long term sickness benefit are less likely to attend a treatment session, Davis et al (2020)http://dx.doi.org/10.1136, as are those who have been referred previously. Thus one might expect this 104,440 to attend a mean of 6 sessions and treatment typically spans 12 weeks according to Saunders et al (2020) https://doi.org/10.1017/S1754470X20000173 . But the population who may return to employment is smaller still because of the following considerations:

  1. There will be a sub-population of the ‘unemployed’ whose unemployment is  related to a work related negative life event, e.g now being physically unable to do the manual work they were employed to do or maltreatment at work. It is difficult to see how 6 sessions of psychological therapy  delivered over 12 weeks would change the diagnostic status of this sub population. There is absence of evidence that such a dosage of psychological therapy can change the employment status of this sub-population. If the sub-population of clients for whom work has been an iatrogenic factor in their debility, are excluded from the analysis, then the population that IAPT’s ministrations could conceivably address is much less than 100,000.
  2.  There will be a further ‘sub-population’ of the unemployed for whom work within their training is simply not available e.g a redundant fisherman. IAPT does not have the resources to conjure up new opportunities, albeit it might direct a client towards re-training.  

Thus the range of action of IAPT with regards to employment status is very limited and even more so when one considers by what mechanism could the typical 6 sessions change employment status over the 12 week span? To return a person to occupational functioning means addressing three key areas a) persistence – the ability to persist with a task b) pace – the ability to complete a task in a timely manner and c) adaptation – the ability to handle the inevitable hassles of the workplace. There is no evidence that IAPT specifically targets these difficulties or has provided training in tackling them. Neither has it been demonstrated that 6 sessions of psychological therapy can resolve such difficulties in 12 weeks and even less evidence as to whether such treatment is enduring.

IAPT lacks the potency to make a real world difference to the unemployed and those on long term sick. Layard and Clark (2014) muddy the distinction between the power of evidence-based psychological therapies and the power of their offspring, IAPT. It can be objected that IAPT pays for itself by increasing the productivity of those already employed, rather than by changing occupational status. But there is no evidence that it does so anymore than the pre-IAPT counselling services.

IAPT’s claim that it changes the employment status of its’ clients is akin to a Dickensian Government’s claim that Workhouses resolve employment issues.

Footnote and reference

 

  1. According to The IAPT Manual 2021 the target for 2021 is 1.5 million clients at a cost of £680 per client [data from Clark (2018) https://doi.org/10.1146/annurev-clinpsy-050817-084833] making the anticipated cost of the service this year, £1.02 billion.
  2. Layard, R and Clark, D.M ( 2014) Thrive: The Power of Evidenced-Based Psychological Therapies Penguin Limited

Dr Mike Scott