What Is The Added Value of  IAPT? 

Last year the Improving Access to Psychological Therapies Service (IAPT) lost 46% of clients before their 2nd treatment session. No other psychological therapy services has such a sink hole.

IAPT ignores the sink-hole casualties in its’ proclamation of a 50% recovery rate. My own independent study, using a standardised diagnostic interview, Scott (2018) suggests that only the tip of the iceberg recover.  

IAPT has a major problem engaging clients. The ratio of those who had one treatment session to those who completed treatment (at least 2 treatment sessions) was 1244386/664087, 1.87 i.e almost twice as many people have just one treatment session  compared to those who complete treatment IAPT Annual Report.

The latest IAPT Annual Report states  that the recovery rate, with CBT, in IAPT is 40.7%, this is less than the 50% recovery rate claimed for the service as a whole.  Its’ 50% recovery rate has been deemed by IAPT  as comparable to the results of randomised controlled trials of CBT for depression and the anxiety disorders. Thus, by its own metric IAPT is underperforming.

                                                         % overlap               Probability of superiority

Effect size is a measure of change. In IAPT for those  at caseness on PHQ9 ( a sore of 10 or more),  the mean initial score was 15.4 (standard deviation 5.5) for those completing treatment (attending 2 or more sessions) and a score of 9.3 (standard deviation 6.4) at the end of treatment, a within subject effect size of 1.1. But a sample of patients undergoing treatment as usual by their GP (with PHQ9 scores of 10 or more and 87% of the sample not treated by IAPT) Gilbody et al 2015  and followed up for 4 months, show an  effect size  score of 1.9. This is based on an initial PHQ9 score of 16 (standard deviation 4.2) and an end score of 9 (presumed standard deviation 4.2), adjusted for the size of the correlation between beginning and end of treatment, using IAPT’s correlation of 0.6, inferred from its data analysis.  This data was input into an Effect Size Calculator, yorku.ca for a within subjects design. There is thus no obvious added benefit to IAPT, rather the reverse.

The burden of proof is on IAPT to demonstrate that it confers any added value.

Dr Mike Scott

The Seriously Flawed Psychological Therapy and Dementia Study

 

Psychological therapy for people living with dementia (PLWD), is the way forward according to a study by Bell et al (2022) focussing on Improving Access to Psychological Therapy (IAPT) clients. The authors reported a 40% recovery rate for people living with dementia, compared to a recovery of 47% in the matched control group without PLWD, they claimed ‘our findings are important for encouraging referrals of PLWD into primary care psychological therapy services, as our work suggests that these services are likely to be useful in treating anxiety and depression in PLWD’. But their study did not demonstrate a real-world benefit for treating PLWD sufferers in IAPT. This is spin in favour of IAPT. The study was funded by the Alzheimer’s Society, who not surprisingly endorsed the author’s conclusion.

Don’t Psychoathologise The Reactions of People Living With Dementia

The twin outcome metrics were the PHQ9 and GAD7, and to enter the study people had to be initially at ‘caseness’ on one of these measures, a score of 10 or more on the former or 8 or more on the latter. Recovery was defined as being below the threshold for ‘caseness’ on both measures at the last treatment encounter. But data was only analysed for clients who completed 2 or more treatment sessions. Data from the most recent IAPT Annual Report (September 2022) , indicates that almost half (46%) of IAPT clients attend one or no treatment sessions. Thus if Bell et al (2022) had included in their analysis those who attended only one or less treatment sessions, i.e they had performed an intention to treat analysis, the true recovery rate would have been significantly less than that claimed. Strangely the authors make no mention of this.

Bell et al (2022) do not consider whether reliance on two self-report measures as the sole outcome metric is problematic. No mention that independent assessments may be important, as the self-report measures that are completed are subject to treating clinician scrutiny and comment. Further there is evidence that patients score lower on the PHQ9 in order to motivate themselves Robinson et. al (2017).  This leads to a mismatch between scores and patients global ratings of change ‘How are you feeling in comparison to 2 weeks ago? [(1=feels much better, 2 = feels better, 3= feels the same, 4 = feels worse, 5= feels much worse]). The within subject effect size for the PHQ9 was 0.83 and for the GAD7 0.80. A less than 1 standard deviation reduction is just what would be expected of an attention placebo control condition, (absent in the said study) involving regression to the mean, with people presenting initially at their worst. The blindness of the authors to these limitations is breathtaking.  The authors declare no conflict of interest, but fail to state that one of the authors works for Icope an IAPT service.

It is likely that volunteer supporters for PLWD would be more welcome than psychological therapists and at least as useful.  The Alzheimer’s Society should look to such a body of volunteers. This is not to say that there will not be PLWD who are suffering from depression and anxiety and need evidence based treatment, but there is no sign of it coming from IAPT any time soon.  IAPT has a remarkable ability to secure funds and endorsements without its therapists having a unique knowledge or training in this case of dementia. There is a credibility gap between IAPT and its’ fellow travellers  and what happens on the ground. 

 

Dr Mike Scott

 

Non-Reply From Health Minister’s Aide On IAPT’s Gatekeeping

Last month I asked Dr Coffey, the Health Minister the following questions, in italics I have summarised the responses from an aide. The full text that I received on October 12th 2022 follows.

1.The Government Improving Access to Psychological Therapies (IAPT) Service is experimenting with public, direct access to a Psychological Wellbeing Practitioner. But PWPs are not trained in diagnostics nor are they qualified therapists. Why then are they being given this gatekeeping role?

Best answered by NHS England


2. The IAPT service has cost billions of pounds, since its’ inception in 2008. Why, then has there been no independent audit of the service?

Not answered


3. With regards to physical health the Government is funding Community Diagnostic Centres, with regards to mental health why is there no facility for reliable
diagnosis in IAPT?

Interesting, but diagnosis in mental health  is ‘less straightforward’, it would be too costly, no plans.

4. With regards to mental health there is no evidence that those availing themselves of IAPT fare any better than those attending the Citizens Advice Bureaux? What then is the added value of funding IAPT?

Not answered

5. How is the experiment of making PWPs gatekeepers being evaluated and who decided on the criteria?

Not answered

6. IAPTs claimed recovery rate of 50% has not been independently verified. The independent evidence of an Expert Witness to the Court [Scott (2021) British Journal of Clinical Psychology] suggests that in fact only the tip of the iceberg recover. Is this not grounds for a publicly funded independent audit?


7. How do we know IAPT is value for money?

Not answered

Dear Dr Scott,
 
Thank you for your correspondence of 18 September Improving Access to Psychological Therapies (IAPT) programme. I have been asked to reply.

NHS England has oversight for the IAPT programme, so would be best placed to respond to your queries. However, delivery of IAPT services is the responsibility of local commissioners. Integrated care boards (ICBs) replaced clinical commissioning groups in the NHS in England from 1 July 2022. A list of ICBs can be found at www.nhs.uk/nhs-services/find-your-local-integrated-care-board/.

In response to question 4, people seek treatment through talking and psychological therapies provided through local IAPT services for anxiety, depression and a range of other mental health conditions such as agoraphobia, post-traumatic stress disorder, obsessive compulsive disorders, panic disorders and social phobias. Treatments can include therapies like counselling, cognitive behavioural therapy (CBT) and peer support. In 2021-22, 1.24 million referrals accessed talking therapies through IAPT services.  The recent annual report available at https://digital.nhs.uk/data-and-information/publications/statistical/psychological-therapies-annual-reports-on-the-use-of-iapt-services/annual-report-2021-22 contains information on referrals, waiting times and patient outcomes such as recovery. In addition, the report covers a range of demographic analyses including outcomes for patients of different ages, ethnic group and separately for ex-British Armed Forces personnel.

For your questions relating to Psychological Wellbeing Practitioners, the IAPT workforce consists of low-intensity practitioners and high-intensity therapists who together deliver the full range of NICE-recommended interventions for people with mild, moderate and severe depression and anxiety disorders, operating within a stepped-care model. All IAPT clinicians should have completed an IAPT-accredited training programme, with nationally agreed curricula aligned to the National Institute for Health and Care Excellence (NICE) guidance (or they should have acquired the relevant competences or skills before joining an IAPT service). All clinicians should be accredited by relevant professional bodies and supervised weekly by appropriately trained supervisors.

Many people with mild to moderate depression or anxiety disorders are likely to benefit from a course of low-intensity treatment delivered by a psychological wellbeing practitioner. Individuals who do not fully recover at this level should be stepped up to a course of high-intensity treatment. The NICE guidance recommends that people with more severe depression and those with social anxiety disorder or post-traumatic stress disorder (PTSD) should receive high-intensity interventions first. NHS England’s available at www.england.nhs.uk/wp-content/uploads/2018/06/the-iapt-manual-v5.pdfcontains further detail on the IAPT workforce, including PWPs.

Question 3 raises an interesting point; however, there would be significant challenges to making this approach work for mental health conditions. Diagnosis for mental health is less straightforward and replicating Community Diagnostic Centres would require a significant expansion in numbers of mental health staff, above and beyond what is already set out in the NHS Long Term Plan that there will be additional 27,000 mental health professionals in the NHS workforce by 2023/24. Therefore, we have no plans at present to replicate this model for mental health.

I hope this reply is helpful.

Yours sincerely,

K Jarvis
Ministerial Correspondence and Public Enquiries
Department of Health and Social Care

 

Dr Mike Scott

IAPT Outperformed by Anxiety UK

In a recent study by Than et al (2022,) outcomes for attendees of the Charity, Anxiety UK have been compared with the results of attending the Improving Access to Psychological Therapies (IAPT) service. The authors claim a higher recovery rate, 62.4%, for Anxiety UK compared to 51.1% in IAPT. Anxiety UK clients attended a mean of 8.53 sessions compared to a mean of 6.9 sessions in IAPT. The results apply for treatment completers only, defined as attending two or more treatment sessions. But only 4.4% attend only one treatment session in Anxiety UK, but for IAPT in the year running up to the pandemic the figure was 44.7%. It seems that Anxiety UK is massively more able to engage clients than IAPT, strangely a point that Than et al (2022) completely missed.

Anxiety UK operates outside the NHS and does not use IAPT’s stepped care model of low and high intensity interventions. Raising the obvious question of why bother with such a distinction? The minimum access standard set for IAPT for 2020/2021 was 25%, suggesting that potentially 75% will not access the service. This makes the case for the provision of non-commissioned services external to the NHS.

But there are reasons to proceed with caution:

  1. Both Anxiety UK and IAPT have marked their own homework. There has been no independent assessment of these two service providers.
  2. They have adopted the same metric, changes in score on two psychometric tests,the PHQ-9 and GAD-7 between the first and last administration of these measures. Neglecting that clients a) may score lower on re-administration, because they don’t want to feel that they have wasted their time in therapy b) may not want to appear ungrateful by scoring near their initial score and c) present initially in therapy at their worst and there is some naturally occurring resolution of difficulties (regression to the mean).
  1. There can be no certainty that the self-report measures are measuring what they purport to measure. The PHQ-9 is a measure of the severity of depression and only has validity if the individual has been reliably diagnosed (using a standardise semi-structured interview) as suffering from depression. Similarly, the GAD-7 is a measure of the severity of generalised anxiety disorder (GAD) and only has validity if the individual has been reliably diagnosed (using a standardise semi-structured interview) as suffering from GAD. It is perfectly possible to score highly on both measures but to have neither disorder, for example a Ukrainian refugee with a sub-syndromal level of post -traumatic stress disorder/ adjustment disorder and for whom psychological treatments might be misplaced as opposed to watchful waiting/support. The danger of relying entirely on self-report measures is that normality is pathologized.

 

  1. Despite the claim of Than et al (2022) measuring outcome by a change of score on on self-report measures is not the most ‘client centric’ form of evaluation. It is essential that an outcome measure must be intelligible to the client, changes in psychometric test scores lack any clear meaning to clients. What clients do clearly understand is whether or not they are back to the former self’s post-treatment or at least back to their best selves and the duration of those gains. Inquiry into these domains by an independent observer is the only way of reliably determining whether there has been real world benefit from treatment. Both service providers have jettisoned, rigorous independent assessment.

 

  1. Neither service provider has run fidelity checks to guarantee that the alleged CBT, clinical hypnotherapy, counselling etc was actually delivered. They both claim NICE compliance, but this necessitates matching a protocol with a reliably diagnosed disorder. Given that neither make diagnoses the claim of compliance has to be fraudulent. It appears an exercise in impression management with Anxiety UK but in IAPT it is arguably more insidious , a mechanism by which funds are secured.

 

  1. The Anxiety UK authors totally ignore the controversy in the British Journal of Clinical Psychology Scott (2021) about the validity of IAPT’s chosen metric and that most plausibly only the tip of the iceberg recover Scott (2018). One service provider might be concerned to demonstrate a better performance than another but the crucial question is what is actually happening at the coal face? Nevertheless, I suspect working conditions are much better at Anxiety UK.

 

Dr Mike Scott

 

 

Mental Health Triage Practitioners Don’t Know Who Is Suffering from What, or What Needs To Be Done

The Government’s Improving Access to Psychological Therapies (IAPT) programme has decided to experiment with enabling the public to directly book an appointment with a Psychological Wellbeing Practitioner (PWP). But IAPT and the Government are keeping quiet, that PWP’s are not trained in making diagnoses nor in providing psychological [ IAPT Manual (2019)]. They have made it impossible for the public to give informed consent. The public are being conned. In the interest of ‘efficiency’, IAPT is by-passing managerial and admin staff. 

For the most part PWPs have nursing or social work backgrounds with a first degree. A recent patient of mine could easily have made direct access to a PWP, I shudder to think what they would have made of his abrupt mood changes, sometimes changed image as he looks in the mirror and periodic disengagement from life. Though not abused himself as a child, he witnessed parental abuse. To put it bluntly they wouldn’t have a clue what was wrong, much less what to do about it. What then is the unique body of knowledge of PWPs?

Given that successive Governments have never conducted an independent audit of IAPT since its inception in 2008, who can say that the billions of £’s service, is value for money? It is to be expected that a service itself will claim itself essential, and in support of this IAPT claims a 50% recovery rate [IAPT Manual (2019)]. But my own independent study Scott (2018) suggests that only the tip of the iceberg recover. As far as mental health is concerned there is no evidence that those  availing themselves of IAPT fare any better than if they had attended the Citizen’s Advice Bureaux. But the CABx is upfront with no pretence at having mental health expertise.  Is the Government running a production line or endeavouring to improve mental health? No answer from the Health Secretary yet.

Dr Mike Scott