The Impact of Child Mental Health Services and NICE

The scale of mental health problems in the young is enormous, of 5-19 year olds 1 in 8 have a mental disorder, and 1 in 20 two or more disorders [The Mental Health of Children and Young People in England (2017). NHS Digital November 2018)]. With a quarter of 11-16 year olds with a disorder self-harming or attempting suicide. Nobody doubts the the importance of reaching out to young people with mental health needs. As a consequence there has been a massive expansion of IAPT services to children and adolescents [ Ludlow, C., Hurn, R., & Lansdell, S. (2020). A Current Review of the Children and Young People’s Improving Access to Psychological Therapies (CYP IAPT) Program: Perspectives on Developing an Accessible Workforce. Adolescent health, medicine and therapeutics, 11, 21–28. https://doi.org/10.2147/AHMT.S196492] with an intended extra 1700 Children and Young Persons IAPT workers by 2021. But there is a paucity of evidence on the effectiveness of this outreach.

Meanwhile NICE have just issued proposed guidance on ensuring the mental wellbeing of pupils. But the only clear advise in its’ summary ‘Social, emotional and mental wellbeing in primary and secondary education: NICE guideline DRAFT (January 2022)’, is to ask schools to consider Mindfulness for all pupils! The focus is on enhancing children’s wellbeing and on strategies that improve their scores on wellbeing measures.  But this is of doubtful relevance to the dire state some children are in.

There is evidence that half of children get over their problems within 12 months without active intervention                 [ Leikanger, E., & Larsson, B. (2012). One-year stability, change and incidence in anxiety symptoms among early adolescents in the general population. European child & adolescent psychiatry, 21(9), 493–501. https://doi.org/10.1007/s00787-012-0284-7]. So any intervention has to do better than this. But I could find no evidence of this. NICE in the proposed Summary guidance writes:

‘The committee discussed evidence on delivering targeted support for children and young people in secondary and further education who have been identified as needing mental health support (for example, because of symptoms of depression.The committee had low confidence in the findings of the quantitative evidence, even though there were quite a lot of studies. There was some better evidence from qualitative studies about the acceptability of targeted support, and the committee had more confidence in these findings. These studies included individual or group interventions or counselling that were delivered by school specialists (suchas school counsellors) or external specialists (such as psychologists)’. [p27 of Conclusions] and added that the same considerations likely apply to primary school children. 

The above paragraph from NICE is confusing, from a methodological point of view quantitative evidence is superior to qualitative evidence [see Cochrane Review BMJ 2011;343:d5928 doi: 10.1136/bmj.d5928 ‘Randomised trials, and systematic reviews of such trials, provide the most reliable evidence about the effects of healthcare interventions’].

A treatment may be acceptable but that tells nothing as to whether it makes a real world difference. 

The proposed Guidance is an abstraction, when I think of recent cases I have encountered:

  1. A secondary school teacher distraught at the continuing sexual innuendos of boys, which resonated with the sense of threat she felt following a serious sexual assault by an adult male. One senior teacher was supportive another not, yet the toxic behaviour continued.
  2. An 11 year old with separation anxiety disorder and a mild phobia about travelling by car, neither of which had been identified or treated by the therapist. School considered she had no academic or behavioural problems but she reported that she ‘hated school’.  The therapy sessions allegedly addressed her ‘anxieties’.
  3. A 13 year old who had missed a lot of schooling because of uncomfortable headaches/disorientation. The therapeutic focus had been on trying to relax. There had been no consideration that she may have a health anxiety problem
  4. An 8 year old girl with separation anxiety disorder who had been given EMDR, switching from negative to positive thoughts at the sound of a beep. The therapy was ineffective and delivered despite no evidence for the efficacy of EMDR for separation anxiety disorder.
  5. A 9 year old boy distraught at spending part of the week with his mother (who had a record of drug addiction) and part with his father. He desperately wanted to be with his father but the social worker and school took the mothers view. The school considered that the child may have ADHD when more plausibly he was distracted by the toxic atmosphere in his mothers home and her boyfriend’s behaviour.

This Guidance would have made no difference at all to any of these cases. The proposed Guidance lacks a real world feel. There is no credible mechanism by which targeting emotional wellbeing, impacts depression, anxiety disorders, separation anxiety disorder, or conduct disorders. Further it is not proven that targeting emotional wellbeing prevents these disorders. Moneys are better spent targeting established disorders than tilting at the windmill of emotional wellbeing, with nebulous targets, such as increasing academic resilience.

As far as we can, we must answer the question ‘which treatment works best, for which child, in which circumstances?’. Answering this requires specificity about treatment, diagnosis and the child’s social context.

Dr Mike Scott

IAPT Has Been A Law Unto Itself and is Rightfully Being Ignored by NICE

The National Institute for Health and Clinical Excellence (NICE)  can only base its treatment recommendations on studies that have a rigorous methodology. In generating the proposed recommendations on the treatment of depression &source=web&cd=&ved=2ahUKEwic8KOfmcD1AhVOasAKHVt8C_EQFnoECAcQAQ&url=https%3A%2F%2Fwww.nice.org.uk%2Fguidance%2Findevelopment%2Fgid-cgwave0725&usg=AOvVaw01CPXDGEYzB5NZCOPcgTFr NICE has ignored all studies that  emanate from the Improving Access to Psychological Therapies (IAPT). Yet the lead organisation for cognitive behaviour therapy, the British Association for Behavioural and Cognitive Psychotherapy (BABCP) BABCP response – NICE consultation draft https://www.google.co.uk/urlsa=t&rct=j&q=&esrc=s has protested vehemently about this. But applying the ‘Psychotherapy outcome study methodology rating form’ developed by Ost (2008) OST the original randomised controlled trials of CBT for depression and anxiety disorders had a mean score  of 27.8, (SD 4.2). Applying the scale to studies by IAPT related personnel, they struggle to score into double figures – a fate shared by studies of low intensity CBT.  To put these scores in context, Ost (2008) dx.doi.org/10.1016/j.brat.2007.12.005 found the total mean score for ACT was 18.1 (SD 5.0) and for DBT 19.4 (SD 3.9). He considered the scores for ACT and BDBT too low, for them to be regarded as Evidence Supported Treatments (ESTs). How much less of an EST then are the IAPT interventions? BABCP defends itself by saying the IAPT studies need to be evaluated by some other metric, but don’t specify which. This sounds suspiciously like the defending of a family member, rather than being data driven.

It should be noted that IAPT does not measure either adherence  (item 15 on the rating form) nor competence (item 16 on the rating scale). Thus there is no assurance of treatment integrity in IAPT. IAPT clinicians have been a law unto themselves. NICE therefore cannot be sure that IAPT’s alleged treatment interventions were delivered.

The studies by IAPT related personnel fail abysmally on almost every index of reliable methodology. Running through the rating form: IAPT therapists do not make diagnoses, making for ‘0’ scores for items 1-6, similarly ‘0s’ would be awarded for no blind evaluators (item 7), no assessor training (item8), no random, assignment to treatments (item 9), no control groups (item 10), treatment as usual (item 11), no power analysis (item 12), only pre and post assessment points  (item 12), effects of therapist were not assessed, nor level of training  [items 14 & 15generously a score of 1 could be awarded on both these items, no control of concomitants (item 18), no intention to treat analyses (item 19), statistical analysis confined to completes (item 20),  no evidence of real world clinical significance (item 21 but a case could be made for awarding a 1 score, no equality of therapy hours because no comparison condition (item 22).  

The low intensity rcts similarly rate very poorly on the rating form. Studies of these cheap offerings rely on establishing statistically significant differences with a comparison group. Never stopping to assess whether any found difference is clinically  meaningful. Any differences do not pass the ‘Does it matter? test, or the ‘So what? test or the ‘Why should anyone care?’ test. In none of the studies have clients been asked independently post treatment  ‘are you back to your usual self, now?’ Importantly if they reply ‘yes’,  then asking ‘for how long have you been back to your usual self?. Studies of the natural history of anxiety disorders have utilised a period of 8 weeks free of  meeting diagnostic criteria, to define recovery, Bruce et al (2005)] The absence of data on the proportion of clients returned to their normal and enduring functioning  by these ‘cost-saving’ interventions, means that prospective clients cannot make an informed choice about engaging in such treatments. NICE needs to proceed more cautiously in recommending low intensity CBT.

 

Dr Mike Scott

The Bell Tolls for IAPT if NICE Has Its’ Way

according to the BABCP’s submission BABCP response – NICE consultation draft  to the National Institute for Health and Clinical Excellence (NICE ). Implementation of the latter’s proposed guidance would mark the end of the Improving Access to Psychological Therapies (IAPT) service. 

Interestingly BABCP recommend that assessment should begin with a reliable diagnostic interview and acknowledges that IAPT’s Psychological Wellbeing Practitioners (PWPs) are not equipped to do this. Further BABCP recommend that outcomes should be assessed from the client’s perspective but do not specify how. Ironically some of BABCP’s own recommendations undermine the functioning of its over-induIged prodigy, IAPT. BABCP are alarmed that the proposed guidance would, in their view, herald the end of stepped-care.

BABCP are aghast that NICE have not included studies by IAPT related personnel in determining the way forward. In defence of IAPT, BABCP cite the Wakefield et al(2021) https://doi.org/10.1111/bjc.12259 study published in the British Journal of Clinical Psychology but fail to mention my rebuttal paper Scott(2021) https://doi.org/10.1111/bjc.12264 published in the same issue of the Journal. Quite simply NICE does not consider studies that are based on agencies marking their own homework as having any credence. This is thoroughly reasonable.

The BABCP have rightly pointed out to NICE that in recommending group interventions as the starting point for offering clients help, they have not properly looked at the context of the group studies. As I pointed out in my submission to NICE COMMENTS ON PROPOSED GUIDANCE (and simultaneously submitting via BABCP as a stakeholder), there are considerable hurdles in engaging clients in group therapy, see Scott and Stradling (1990)Group cognitive therapy for depression produces clinically significant reliable change in community-based settings Behavioural Psychotherapy, 18: 1-19 and Simply Effective Group Cognitive Behaviour Therapy Scott (2011) https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiph5Hlvbb1AhWKX8AKHRSJDZ0QFnoECAUQAQ&url=https%3A%2F%2Fwww.amazon.co.uk%2FSimply-Effective-Cognitive-Behaviour-Therapy%2Fdp%2F0415573424&usg=AOvVaw0nam02gszlQ0HqCktSCB0s. 

In fairness, I think Prof Shirley Reynolds from BABCP has done a great job in reviewing the extensive documentation provided by NICE and collating the individual submissions, all within a very brief period of time. I understand from her that these matters will feature in the next issue of CBT Today and whilst I was happy to have my name noted as having submitted, there are important aspects of the submission on which I wish to dissent.

NICE make its’ formal recommendations in May, interesting times

 

Dr Mike Scott

More Treatment But No Less Disorder: What Is Going on Here?

 

a soon to be published study by Ormel et al https://doi.org/10.1016/j.cpr.2021.102111 highlights the increased access to psychological therapies but notes that the population prevalence of disorder has not decreased. The authors term this the ‘treatment-prevalence paradox’ (TPP) and although their focus was on depression, it likely applies to all the common mental disorders. They consider that the most likely explanations are that:

(a) the published literature overestimates short- and long-term treatment efficacy,

(b) treatments are considerably less effective as deployed in “real world” settings, and

(c) treatment impact differs substantially for chronic-recurrent cases relative to non-recurrent cases.

 

Efficacious treatments are it seems, likely lost in a fundamentalist translation that preserves the reputation of service providers. Independent corroborative evidence of effectiveness is non-existent.

In the event of the statistically likely, ‘real world’ failure of a psychological treatment how should a clinician respond? With dismay, if he/she is an IAPT therapist enjoined to demonstrate a 50% recovery rate. The pressure to manipulate test results will be great, ‘on item x did you really mean…’ . The therapist might protest that any one case is ‘complex’, but such a claim is likely to be given short shrift, with repeated vocalisations.  A suspicion of ‘incompetence’ lurks, which may be at least temporarily assuaged, by agreeing to go for further training. But the dice are it seems loaded in favour of burnout, this New Year.

There is no IAPT protocol for treatment failures.  In a spirit of apparent openness A GP may be invited to re-refer  if ‘appropriate’. The latter might just do this if badgered by the patient at some future point. But given that the same assessment and treatment procedures will be in place, another spin around the revolving door is the most likely outcome. IAPT in effect puts most client’s in a waste-paper bin, some are recycled to no avail.

 

The TPP will continue until service providers enable therapists to ask ‘who, needs what treatment?’. Following the mnemonic PICOT, the ‘who’ is determined by  asking which population (P) is this person representative of? There are ‘gold standard’ semi-structured diagnostic interviews to clarify the best fit between a person and a patient population. The use of short-cuts (heuristics) such as solely relying on a test result or highlighting a particular symptom of a disorder, leads to mis-diagnosis and an inappropriate intervention – the I of PICOT. The I should follow  a published treatment manual that specifies the treatment targets and matching treatment strategies for the particular identified disorder. But a treatment protocol lacks credibility if its efficacy was not assessed by comparison (the C) with an active control condition. Similarly outcome studies (the O) lack credibility if they did not involve blind independent assessors. T refers to the duration of follow-up, all conditions wax and wane, so assessment at any one point can simply be ‘ flash in the pan’, enduring change is the mark of recovery.

Service providers, such as IAPT should ensure that they make therapists aware of  the quality of the foundation for the chosen intervention, but this is rather like getting turkey’s to vote for Christmas! Courses run by Academic Institutions for IAPT dare not risk biting the hand that pays them. 

 

Dr Mike Scott

Cost Of Improving Access to Psychological Therapies (IAPT) Last Year, Over £1bn, But No Independent Corroboration of Effectiveness

A contemporary of Mark Zuckerberg has been arrested because there was no independent evidence that her scanners could furnish 100’s of blood results from just a few drops. There is it seems more accountability in Silicon Valley  than in the UK mental health services. The IAPT (Improving Access to Psychological Therapies) target for 2021 was 1.5 million clients at a cost of £680 per client [data from Clark (2018) https://doi.org/10.1146/annurev-clinpsy-050817-084833] the anticipated cost of the service was £1.02 billion. Where is the evidence that this was value for money?

 Recently I saw a lady who was suffering from a DSM-5 defined phobia about travelling as a passenger in a car, as assessed with a ‘gold standard’ diagnostic interview. But this was not targetted by IAPT, the Psychological Wellbeing Practitioner wrote to the GP thus  ‘completed an assessment .. presenting problems identified  (please note : this is not a formal diagnosis): GAD and depression. .. waiting list Step 2 CBT Guided Self-Help PHQ9 11 GAD7 8′. This lady was not suffering from GAD or depression and appropriate treatment was not flagged up. There is no evidence that GSH is an evidence based treatment for a specific phobia. IAPT uses diagnostic terms to confer legitimacy on its’ endeavours but then seeks to avoid being held accountable by saying that it does not make reliable diagnoses! With IAPT the NHS has bought a pig in a poke.

Dr Mike Scott