IAPT’s Researchers Failure to see the Elephant in the Room

 a meaningless outcome measure.

The January issue of the American Journal of Psychiatry, contains a paper by Delgadillo et al https://jamanetwork.com/journals/jama/fullarticle/10.1001/jamapsychiatry.2021.3539?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamapsychiatry.2021.3539 claiming that 52.3% of those routed along a stratified treatment pathway showed a reliable and clinically significant improvement (RCSI), compared to 45.1% along the Improving Access to Psychological Therapies (IAPT) usual stepped care pathway. The additional cost of the stratified pathway was £104.5 per patient, representing the additional time devoted to a patient  to determine the data needed to put into an algorithim and determine whether low intensity should be first or high intensity first. The authors concluded that for this additional sum there was approximately a 7% increase in the probability of RCSI. But at no point do the authors question the validity of adopting IAPT’s self-report metric for outcome.

 

There has never been independent assessment of treatment outcome in IAPT. Further there is no evidence that the changes in IAPT self-report measures represent an added value over the comparable changes when counselling was employed pre-IAPT. There are a number of reasons why there would be improvements on self-report measures as treatment progresses that have little to do with therapeutic effectiveness including: A) regression to the mean, as patients tend to present initially at their worst B) the test results are a focus in therapy, creating a demand issue for the patient and C) patients, understandably, do not wish to feel they’ve wasted their time.

IAPT ignores the fact that the context in which a psychometric test is conducted is crucial. Used in isolation, they are a mirage of the client’s real-world concerns. The RCSI is a perfectly reasonable outcome measure if used in a controlled trial in which the diagnostic status of the patient has been assessed with a standardised reliable interview, at the beginning and at a minimum post-treatment. But in the Delgadillio et al (2022) study, as in all IAPT studies, no diagnosis is made using in gold-standard semi-structured interviews. The population addressed lacks specificity, the only boundary for entry into the study was a PHQ9 score greater than 10, making replication highly problematic. The title of the Delgadillio et al (2022) study suggests that focus was on depression but there can be no certainty that this is actually that case.

 

The Delgadillio et al (2022) study does not address whether a patient would see the apparent difference in outcome between stratified approach and a step approach as a difference that matters. It is impossible to gauge from study what proportion of patients lost their diagnostic status along the differing trajectories. The self-report measures used by refer to functioning in the previous two weeks, patients typically have their treatment’s terminated when their score falls below a threshold of 10 on the PHQ9. But anxious and depressed patients experience waxing and waning of symptoms so that a reliable outcome must specify the duration of recovery, for example eight weeks. The supposed recoveries in IAPT could often be flashes in the pan.

Dr Mike Scott

Reference

Delgadillo J, Ali S, Fleck K, et al. Stratified Care vs Stepped Care for Depression: A Cluster Randomized Clinical Trial. JAMA Psychiatry. 2022;79(2):101-108. doi:10.1001/jamapsychiatry.2021.3539

 

485 words

 

 

The Public Mental Health Information Centre

is a new body set up by the Royal College of Psychiatrists https://www.rcpsych.ac.uk/improving-care/public-mental-health-implementation-centre to ‘Provide high-quality evidence, advice and recommendations on public mental health to government and other policy-making bodies at local and national levels’. They add ‘If you think that there is an opportunity for us or would like to explore working with us, please contact us at public.MH@rcpsych.ac.uk.’ The PMHIC ‘are keen to Support collaboration and leadership on public mental health with a broad range of stakeholders’. All very laudable, but stakeholders have a vested interest in the perpetuation of their own service. For over a decade the stakeholders have managed to mark their own homework. They are charming, hidden persuaders, with the ear of the powerful.

A starting point for the PMHIC would be to review the independent evidence on the effectiveness of routine psychological interventions in primary and secondary care. But insisting on the outcome measures that are used in the best randomised controlled trials of psychotropic medication. The PMHIC could then make a judgement on the current quality of the evidence on effectiveness and suggest ways forward to improve the quality. In the 21st Century it should no longer be acceptable that treatment recommendations are based solely on the consensus judgement of ‘experts’, many of whom have conflicts of interest.

Dr Mike Scott

Restorative CBT for Post-traumatic Stress Disorder and Beyond

New youtube video https://youtu.be/3UeJ1Lux4pU detailing how to help the client back to their old selves post trauma – Restorative CBT (RCBT). Not only for those who have developed PTSD but also for those who have acquired other disorders, whether singly or in combination. The video is based on my new book ‘Personalising Trauma Treatment: Reframing and Reimagining’, available from amazon https://images-na.ssl-images-amazon.com/images/I/5141wjLVgrL._SX331_BO1,204,203,200_.jpg. and published by Routledge.

RCBT is likened to restoring a dilapidated property but in some instances it may be a rebuild on the same site, for those who feel they have never functioned well. Mental time travel to a trauma/s is inevitable but it is what the person takes it to mean about today that is crucial for possible ongoing psychological debility. It is the centrality accorded to the trauma that is pivotal in the development of disorder. The book is replete with metaphor making for ease of dissemination. For example, PTSD clients are invited to consider that they are wearing a pair of ‘war-zone’ glasses and are invited to practice swapping these for the ‘spectacles’ that they would have worn in the weeks before the trauma.

It is suggested that a) there is no credible evidence that traumatic memories are  different in kind to ordinary autobiographical memories and b) traumatic memories do not have unique neural basis. Consequently there is no need for clients to relive their trauma. It is much easier for clinicians and clients to consider the adaptiveness of a memory than to relive it to the point of desensitisation. In randomised control trials, trauma focused interventions result in recovery in about 50% of cases. However in routine practice because of comorbidity and population differences, the proportion is likely to be significantly less. Further to the extent that trauma-focussed interventions work, they may do so simply because the client collects experimental evidence that they are not in a ‘war zone’. There is then ample justification for approaching the psychological sequelae of trauma from an RCBT perspective.

 

Dr Mike Scott

 

 

Forget Trauma-Focussed Interventions, Deliver Restorative CBT

Restorative CBT(RCBT) focuses on getting the trauma victim back to their old selves, as far as possible. It does not require the client to relive the trauma. The difference between RCBT and trauma focussed CBT (TFCBT) is stark when it comes to considering long-term psychological help for those affected by the war in Ukraine. A theme throughout the book is helping trauma victims forgo the ‘war zone glasses’ through which  they may view their current environment. The RCBT approach is likely to be more acceptable and easier to disseminate. The specifics are in my book ‘Personalising Trauma Treatment: Reframing and Reimagining’ https://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwi_sby24qz2AhUOa8AKHfyaCFYQFnoECAEQAQ&url=https%3A%2F%2Fwww.taylorfrancis.com%2Fbooks%2Fmono%2F10.4324%2F9781003178132%2Fpersonalising-trauma-treatment-michael-scott&usg=AOvVaw1vevwk6WE3_-ghkv14ZpM2 published by Routledge, March 2022. The accompanying commentary and slides give a taster http://www.cbtwatch.com/wp-content/uploads/2022/03/Forget-Trauma-Focussed-Interventions-1.pptx see also Youtube https://studio.youtube.com/video/FN_ck6iCIpE/edit . Do get back to me if you would like to discuss cases. 

 

In this book, clients are taught to rediscover their sense of self by reframing the trauma. Within this new framework the focus is on the client’s mental time travel from the trauma to today and reimagining their future. The therapeutic targets are the thoughts and images (cognitions) that interfere with day-to-day functioning. It does not assume that arrested information processing lies at the heart of the development of PTSD, with a consequent need for the client to re-live the trauma. For those clients who were abused in childhood, their experiences are viewed through a particular central window, but other ‘windows’ may make for more appropriate engagement with their personal world and a reimagining of their view of themselves. Treatment delivery options from telephone consultation, group work and videoconferencing are discussed. With illustrative examples, the author highlights the pathway to recovery for a wide range of clients with the comorbidity often found in real-world settings.

The book will be essential reading for therapists and other mental health professionals working with trauma survivors.

Dr Mike Scott

Another Nail In The Coffin of IAPT

A year ago the British Journal of Clinical Psychology published my paper ‘Ensuring that the Improving Access to Psychological Therapies (IAPT) programme does what it says on the tin’  60(1), 38. https://doi.org/10.1111/bjc.12264. This month in the Journal there is a further damning indictment by Martin et al (2022) ‘Improving Access to Psychological Therapies (IAPT) has potential but is not sufficient: How can it better meet the range of primary care mental health needs?’ 61, 157–174, DOI:10.1111/bjc.12314.

Here are the main points from Martin et als’ BJCP paper:

  •  Improving Access to Psychological Therapies(IAPT)has significantly increased access to psychological therapies within primary care over the last decade, though it is unclear whether its interventions are sufficiently tailored to meet the actual levels of complexity of its clientele and prevent them from needing onward referral to secondary care as originally envisaged.
  •   Given the ongoing focus on and investment in IAPT informed developments into long-term conditions and serious mental illness, this review considers whether additional elucidation of the model’s original objectives is required, as a precursor to its expansion into other clinical areas.

  •   There view indicates that there is a stark lack of data pertaining to the generalisable, real-world clinical benefits of the IAPT programme as it currently stands.

  •   Recommendations are provided for future areas of research, and practice enhancements to ensure the value of IAPT services to clients in the wider context of NHS mental health services, including the interface with secondary care, are considered.

 

The British Association of Behavioural and Cognitive Psychotherapies (BABCP) ought to look seriously at the promotion of its’ IAPT comic ‘CBT Today’. Interestingly in its’ recent issue it managed to omit that I was one of those who made a submission re: the proposed NICE Guidance on depression. Further, only one of the others who made submissions were given their adjectival title, the leading light in IAPT. The British Psychological Society (BPS) should reconsider its validation of low intensity IAPT courses, in the absence of any credible evidence base on real-world effectiveness.

Dr Mike Scott

Ignoring Mental Health Outcomes That Matter

this is a speciality of Government provided services. Studies of the natural history of depression and the anxiety disorders insist on using evidence of enduring freedom from the disorders of                     8-12weeks [Bruce et al 2005https://doi.org/10.1176/appi.ajp.162.6.1179 and Penninx et al (2011) doi:10.1016/j.jad.2011.03.027] as evidence of remission, distinguishing the latter from a new episode of the disorder. This reflects the general public’s understanding of having a disorder or not having a disorder. But inspection of the Government’s Improving Access to Psychological Therapy (IAPT) service reveals no such clarity. Instead funders of services and clients are invited to believe that the latter endorsing a below 10 score on the PHQ9, over the previous two weeks,  is evidence of appropriate treatment. Further the scoring is discussed with the therapist, usually resulting in an exit from the Service when this promised land is reached. But it is entirely a mirage, that suits IAPT’s need to secure funding. The narrow interest of the Service is put above the public good. 

IAPT’s metric ignores the complexity of presentations, client’s may present with depression an anxiety disorder or a combination of the two, each follows their own trajectory [Penninx et al (2011) doi:10.1016/j.jad.2011.03.027]. But there is no reliable identification of who is on what pathway, as IAPT clinicians do not make diagnoses [IAPT Manual (2019)]. It is therefore impossible to match treatment to diagnosis. Further IAPT takes no steps to ensure treatment fidelity i.e the matching of a treatment strategy to a target. 

The mnemonic PICOT has been used by NHS England and NICE to help determine evidence based treatment. The P stands for population  or the problem being addressed. IAPT’s gateway criteria for disorders are scores over 10 on the PHQ9 or over 8 on the GAD7. But what does this tell us about this population? Are they suffering from depression and/or an anxiety disorder? which anxiety disorder? Can there be any certainty that they are not suffering from an adjustment disorder or possibly PTSD? In what way would this population differ from another population that they might resemble? The ‘P’ of the PICOT in IAPT is so fuzzy that it sabotages any pretence by the service to deliver an evidence based treatment (EBT). IAPT has no fidelity  checks, making it impossible to specify the I. IAPT has never attempted to compare its’ service effects with effects of pre-IAPT counselling, thus it has never attempted C a comparison, making it impossible to state the ‘added value’ of its ministrations. IAPT has declared its’ own outcome of interest and measured in its presence, it is not a primary outcome used in any randomised controlled for depression and the anxiety disorders. The selected outcome measure is self-serving. IAPT takes a photo of the client in a 2 week period when with their assistance they appear to be doing well. This is like defendants Insurers taking video footage of client claiming  an acquired injury, with snapshots of him/her going to the shops, sometimes accompanied,  over a 2 week period.  It says nothing of their fitness to persist in a pre-existing manual job. There is no meaningful distilation of the T in PICOT. IAPT’s practice makes it impossible to evaluate the service according to the NHS and NICE recommended PICOT framework.The IAPT data set is insufficient to meet the PICOT criteria above, at each level.

IAPT operates in a pre EBT mode, relying simply on the judgements of practitioners and by reference to the designated ‘Experts’ within the Organisation, oftentimes nominated by the British Association of Cognitive and Behavioural Psychotherapies (BABCP). The ‘nominations’ are not advanced by BABCP’s claim to be the ‘lead organisation’ for CBT, it certainly does not lead to the promised land. My own research Scott M. J. (2018). Improving Access to Psychological Therapies (IAPT) – The Need for Radical Reform. Journal of health psychology, 23(9), 1136–1147. https://doi.org/10.1177/1359105318755264suggests that only the tip of the iceberg recover in IAPT.

The IAPT training courses fail to equip clinicians with the skills to avoid being led astray, making my real world findings of effectiveness or the lack thereof, unsurprising.

 

Dr Mike Scott