Children In Care Go Down A Rabbit Hole When It Comes to Diagnosis and Treatment

Their world becomes Alice In Wonderland like. A recently published study by McGuire et al (2022) gave one of two alternative vignettes to 270 mental health professionals. The only difference in the narratives was that in one the child was described as being in care and in the other as living with their mother. For the sample in which the child was described as living with their mother, the rate of diagnosis of PTSD was more than double (31.0% vs 14.5%). According to NICE, children with PTSD should follow a particular treatment pathway, trauma focussed CBT. Thus for every child in care placed on the  correct NICE pathway, another would be misdirected. Matters were even worse than this, as only one half of those who diagnosed PTSD recommended a NICE approved treatment (trauma Focussed CBT or EMDR).

Overall the most popular diagnosis was developmental trauma (57.3%)  followed by attachment problems (22.1%) and PTSD (14.5%). But these clinicians seemed unphased, that there is no evidence-based protocol for either developmental trauma or attachment problems. The use of such diagnostic labels is an exercise in unbridled clinical judgement that serves the interests of neither the children in care  nor the troubled child not in care.

Unfortunately the use of idiosyncratic rules of thumb (heuristics) is commonplace, 9 out of 10 of those diagnosed with ADHD are boys, but boys are only 3 times as likely to have ADHD as girls, Bruchmuller et al (2012) the representativeness heuristic operates, in that boys are seen as prototypical. Heuristics short circuit decision making, sacrificing accuracy for speed. But they are not the exclusive preserve of clinicians working with children, their usage is ubiquitous  amongst mental health professionals. It is an article of faith amongst aspiring mental health clinicians that the ‘medical model’ must be derided at every turn, diagnosis is anathema to be replaced by the autocracy of the clinicians judgement. But it is unfettered clinical judgement, imagine what would happen if Judges engaged in this with regards to sentencing! Diagnosis is built on explicit criteria and another clinician can challenge whether there is sufficient evidence that those criteria are/were met. We can even distil more reliable diagnostic criteria. There is no appeal against the autocracy of unbridled clinical judgement, it is an exercise in power without responsibility. We are back to the era that pre-dated the randomised controlled trials of psychological interventions in the 1970’s. It was like being at the Mad Hatter’s Tea Party, I remember having the timidity to ask on a social work course ‘does this social casework, work?’ and arriving late for a T Group, to be told this was a manifestation of ‘resistance’, my remonstration that I had missed the bus counted for nought.  The social casework totally failed, with failures to protect children abounding and idiosyncratic decision making, supplemented with box ticking.

 

Dr Mike Scott

Spurious Claims For The Impact of Transdiagnostic CBT on Persistent Physical Symptoms 

 

In a just published study James et al (2022) extol the virtues of their transdiagnostic CBT therapy (plus standard medical care) for Persistent Physical Symptoms.
s. In an earlier study  these authors found no difference in outcome at 52 weeks follow up on the Work and Social Adjustment Scale (WSAS: the declared primary outcome measure) between those undergoing the transdiagnostic CBT plus standard medical care and those having the latter alone. Not to be outdone they have gone on a fishing expedition in their latest paper  James et al (2022) and focus on two secondary outcome measures, WSAS score at the end of active treatment  and the PHQ-15 score at 52 weeks, claiming that there was a significant difference between the transdiagnostic CBT  and standard medical care using both these secondary measures.

 This looks a little fishy as they are the originators of the treatment. No mention of the need for independent replication of their findings. Further the comparison group was standard medical care, but this design does not control for attention or the presentation of a credible treatment rationale. Scepticism seems in order. This intensifies when the outcome measures used are considered.

The WSAS (Mundt et al 2002) was designed to assess the impact of mental health on functioning in 5 domains work, home management, social leisure activities, private leisure activities and close relationships. As such there is clear separation between the causal agent (mental health) and effect (functioning). In the initial validation study the WSAS was administered to a sample of depressed patients and a sample of OCD patients, the WSAS scores correlated with the severity of each disorder.  

Mental Health can affect one’s ability to do certain day-to-day tasks in their lives. Please read each item below and respond based on how much your mental health impairs your ability to carry out the activity. 

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If however the term ‘mental health’ in the above table is replaced with “Persistent Physical Symptoms’ the distinction between causal agent and effect is lost. Consider, a person who is terminally ill with cancer or a progressive neurological disorder, they would likely score high in each domain. But it would not be anticipated that any psychological intervention is going to attenuate their physical symptoms, because there is a fusion of physical symptoms and impairment. [In the original validation study the term ‘disorder’ was used because they were known to have either depression or OCD].

The burden of proof is on those who would reword the WSAS so that it related to PPS to demonstrate a meaningful distinction between say fibromyalgia and impairment in functioning or irritable bowel syndrome and functioning or between chronic fatigue syndrome and functioning. The WSAS was not validated for PPS  but that has not stopped James et al (2022) using it as their primary outcome measure in their study of transdiagnotic CBT for PPS compared to standard medical care.

 

The PHQ-15 is a measure of symptom severity and is rated on a 3- point Likert scale. This brief validated measure looks at a range of symptoms and asks patients to report to what extent their symptoms bothered them in the past four weeks. The PHQ-15 contains 15 items and the total score can range from 0 to 30 where a higher score indicates greater symptom severity (Kroenke et al., 2010). The items include several related to pain, (stomach pain, back pain, pain in arms and legs or other joints, headaches, chest pain), fatigue, as well as other symp- toms related to the different systems of the body i.e. shortness of breath, dizziness, bowel symptoms.

But there is no clear mechanism by which a psychological intervention impacts such an array of symptoms. The authors considered 9 possible mediating variables (7 of which were cognitive), but only 2, catastrophising and symptom focusing appeared operative (Type 2 error). Suggesting that the supposed mediating variables may be chance findings. One of the suggested variables related to depression (PHQ-9) and the other anxiety (GAD-7) but for the supposed cognitive mediation model evinced by James et al (2022), they cannot be mediators, depression is known to covary with WSAS as such it cannot be an explanatory variable.

Assessment in the study is entirely by self-report measures but the authors totally ignore that they are subject to demand characteristics e.g wanting to please the therapist by reporting improvement or to convince oneself that time has not been wasted. It would have been more meaningful for an independent assessor to ask since ‘x’ have you felt the same, a little better, a little worse, much better, much worse.  

James et al (2022) justify their transdiagnostic therapy on the basis that ‘people with different PPS share some cognitive and behavioural responses to symptoms, including catastrophising, symptom focusing, fear avoidance beliefs, avoidance behaviour and lack of acceptance (Deary, Chalder, & Sharpe, 2007)’. This is a sweeping statement certainly catastrophising and avoidance behaviour have been implicated in the development of chronic pain, but this is not to say that they are germane to the category of PPS (MUS). The use of the term ‘some’ makes the Deary, Chalder, & Sharpe, 2007 model incapable of falsification.

 

The  term PPS as used byJames et al (2022), is a smokescreen for the construct Medically Unexplained Symptoms whose validity Keith Geraghty and I have challenged.

Dr Mike Scott

 

Mis-Guided Self Help In IAPT

A just published study by Duhne et al (2022)found that almost a third (29%) of those assessed by the Improving Access to Psychological Therapies Service (IAPT) and referred to Guided self-help (either face to face or computer assisted CBT) did not attend any treatment sessions. Whilst of those who attended treatment over half (54%) dropped out, defined as attending three or less treatment sessions. These figures are much higher than the 20% Swift and Greenberg (2012) of clients who typically dropout of psychotherapy.

 

Curiously the authors miss the obvious implication that GSH is misguided. Instead they recommend further investigating an algorithim for better matching those who would do better in cCBT or better in face to face! Why is this? The authors declare no conflict of interest, but the Department from which it emanates at Sheffield University has a long list of IAPT teachers. There is a complete absence of critical appraisal of IAPT’s metrics suggesting that the Sheffield researchers don’t want to bite the hand of a service that gives them a ready-made data set, it eases the research burden. The Journal in which it was published Behaviour Research and Therapy characteristically ignores any criticism of IAPT.

 

Concluding anything  about the relative merits of cCBT and face to face GSH is problematic, in the Duhne et al (2022) study as the mean initial PHQ9 scores  were respectively 12.32 and 15.01, which is statistically significant p < 0.0001, when the sample sizes and standard deviations  are input into a the MedCalc comparison of means calculator.  This suggests some systematic bias in the allocation of people to these modalities. 95,088 patients accessed diverse low-intensity interventions: GSH (n = 84,503; 88.4%), psychoeducation groups (n = 8671; 9.1%), cCBT (1611; 1.7%), and other interventions (n = 753; 0.8%). 

Dr Mike Scott

IAPT Fails The Traumatised

The Improving Access to Psychological Therapies (IAPT) latest annual report states that the recovery rate for PTSD sufferers (24,097) given CBT was 13.1% . Whilst the recovery rate for those receiving EMDR (4,908) was 11.4%. By its own metric only the tip of the iceberg recover. 

 

In total IAPT treated (defined as attending 2 or more sessions) 34,328 PTSD cases and offered 15 different therapies, despite only 2 (CBT and EMDR) being NICE compliant. 15% of cases were given a non-NICE compliant treatment – whither the Services claim of NICE compliance?. With 70.2% given CBT and 14.3% EMDR. For those undergoing EMDR 4153 are on their first course but 2268 are on their second course i.e of those undergoing EMDR over a third 35.32% are on their 2ndcourse. This is not what a person expects to happen.

The metric of recovery used by IAPT for these PTSD cases is the PHQ9. This is clearly bizarre, as the PHQ9 is a measure of the severity of depression. A possible defence of IAPT’s dismal failure to help the traumatised, would be to admit that its method of auditing, of PTSD cases in particular, has been seriously flawed. But unfortunately IAPT behaves like politicians when confronted with manifest failure.    

In IAPT if a person has PTSD there is a 97% (31,570/ 34,328) chance  of them scoring above 10 on the PHQ9. But if a person does not have PTSD (591, 492) only 1077/592,623 or 0.18% would be correctly identified by a PHQ9 score of below 10. Thus using the PHQ9 for detecting PTSD has poor specificity. It is a totally useless metric for identifying PTSD, and would yield an enormous number of false positives. The same results apply if the GAD7 is used as the metric. Whichever metric is used these two measures are useless for detecting PTSD and create false positives resulting in unnecessary treatment.

 

IAPT details the trajectory of PTSD clients going through its’ service yet claims in its Manual that the Service does not make diagnoses. Only politicians can square such circles, alas for us mere mortals. The gold standard in a PTSD outcome study is to use a standardised reliable diagnostic interview, IAPT is yet to overcome its lifelong phobia about their use. One can only suppose that there is a fear of starkly revealing their inadequacy and it is easier to hide behind expressions of concern over cost.

In my own study, Scott (2018) of 90 cases going through IAPT assessed using the SCID diagnostic interview, for those with PTSD the recovery rate was 15%. Again we are looking at the tip of the iceberg of recovery.

IAPT’s training of its therapists with regards to trauma is clearly amiss, it may be that the positive (50% recovery) trauma focussed trials that they draw upon are not sufficiently user friendly to deliver in routine practice and I have detailed an alternative Scott (2022).

Dr Mike Scott

The Health Minister and NHS England Pass The Buck on Answering Key Questions on Mental Health

The previous Health Minister, Dr Therese Coffey was asked 7 questions about the effectiveness of routine psychological therapy for depression and the anxiety disorders. Only 1 of the 7 questions was answered and that, only partially. The Department of Health  advised that NHS England were better placed to answer my questions and so I put the queries to them.  I wrote about this in my blog for Mad In America.  Since then NHS England have replied, or rather not replied, suggesting that I put the questions to my local Integrated Care Board (ICB’s are the recent replacement for Clinical Commissioning Groups). My questions obviously relate to national policy and not local difficulties, it is completely disingenuous of NHS England to reply in this way. I have now asked them for a considered response to my questions.

For the sake of completion I have reproduced the questions below:

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?

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?


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?

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?

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

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?

 

It seems likely that only politician-like responses will be forthcoming. Will nobody grasp the nettle?

 

Dr Mike Scott