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BABCP Response - NICE Consultation January 2022

The Myth That IAPT Costs Nothing – it takes money away from where there is real need 

 

The leading lights in the development of the Improving Access to Psychological Therapies service Layard and Clark (2015) have claimed that it costs nothing, due to savings on welfare benefits and physical healthcare costs. But there has been no independent verification of this claim.

Last year the amount spent on IAPT for 47 providers was £547.2 million according to Government figures with 4 million appointments. But only 5% of IAPT clients are on long term sickness benefit and in the last year, by the end of treatment, only 5%  of these were no longer on benefit, amounting to 1783 clients. Using the figure of £650 furnished by Layard and Clark (2015) as the amount the State saves in a month by getting a person off benefit, the total saving that would accrue from IAPTs ministration in getting the 1783 clients off benefits would be £1.16million. This doesn’t even begin to compare with the totality  of IAPT’s cost. Even were one to assume these clients were all off benefit for a year, a saving of approx £15million, the impact on the total cost of IAPT is miniscule, there is no way that IAPT pays for itself!

I could find no published data that compares the proportion of people IAPT gets off benefits with the proportion of people who would have come off benefits before the inception of IAPT. One can imagine that if one tracked a population of Citizens Advice Bureaux attendees a proportion of them would move off benefits, but would this be any more or less than those going through IAPT?

There is a lack of clarity on the specifics and unique way in which IAPT gets clients off benefits.

There is no independent evidence of the effectiveness of IAPT with depression and anxiety disorders in the context of an established physical disorder. Layard and Clark (2015) appeal to CBT studies conducted in in this population, but there is no evidence that IAPT staff have followed such protocols. IAPT does not employ measures of treatment integrity. Nor is there any documented evidence of savings in physical healthcare costs as a result of IAPT’s ministrations.

The National Audit Office has perpetuated the IAPT myth by steadfastly failing to investigate the Services claims. Friends in high places. But each IAPT appointment costs £136, last year, if at each appointment the client was given this sum for their heating/ living expenses it would I believe make a much greater contribution to the common good. I have just seen on TV a single mum with 3 young children from the North East, as she attends a foodbank, in tears as she battles with heating and food costs.

 

Dr Mike Scott

 

 

 

Categories
BABCP Response - NICE Consultation January 2022

IAPT’s Capitalisation on Time Is A Great Healer

The natural recovery rate for depression is 50% within 6 months. The Improving Access to Psychological Therapies (IAPT) claim a 50% recovery  rate for its clients. It is therefore not at all obvious that psychological treatment has conferred any benefit. The rate of natural recovery from depression is about 2% per week. Looking at natural recovery in generalised anxiety disorder (GAD), of those who had ever suffered GAD, 72% had not had it in the past year. Whilst recovery rate from depression and anxiety disorders at 2 year follow up was 41.7%. These high rates of natural recovery offer Service providers, such as IAPT, a golden opportunity to claim that they have played a pivotal role in client’s recovery. 

Many, many years ago I had a Summer job working part of the time in a Mortuary, the day I began was a glorious Summer’s day and the most Senior pathologist remarked that  ‘you’ve brought the good weather with you’. Much as I had a tendency to take credit when things went well, and to blame others when it didn’t, I did feel that even I couldn’t take credit for the good weather. But Service provider’s it seems have no such inhibitions. They operate with a self-serving heuristic in which the exact mechanisms by which they bring about change are left unattended and they invite others to believe their eminent representatives. In this way effortful processing of data is by-passed, by an appeal to ‘credible sources of persuasion’ as it is termed in the Elaboration Likelihood Model of Persuasion.

Within this ‘Capitalisation’ it easy to smuggle in other purported benefits of psychological therapy such as getting people back to work, improving their physical health without actually demonstrating either, see Layard and Clark (2015) by simply saying ‘it is likely’. All to the glee of politicians, Clinical Commissioning Groups and media. Thus the band wagon continues in a race to the bottom.

 

Dr Mike Scott

Categories
BABCP Response - NICE Consultation January 2022

IAPT – The Rogue Santa

If Santa lost half his deliveries before reaching the 2nd home on his itinerary, he would be viewed with suspicion. But last year the Improving Access to Psychological Therapies Service (IAPT) lost 46% of clients before their 2nd treatment session. What’s going on?

The Service would prefer to deftly switch attention to treatment completers, defined as those who complete at least two treatment sessions. But no Oncology or Physiotherapy service would define completion of treatment in such a minimalist way. This looks like sleight of hand. Nevertheless for ‘completers’, IAPT offers the defence of effectiveness  across a range of disorders as evidenced by the effect sizes in the Table below:

 

IAPT’s Defence By Disorder

 IAPT’s 2021-2022 Annual Report

Within Subject Effect Size using PHQ9 (for all cases initially at caseness) and only for those who completed two or more treatment sessions.  The ES is pre-treatment mean minus the post-treatment mean/pooled standard deviation 

Depression

1.5

Agoraphobia

0.8

Body Dysmorphic Disorder

1.2

Generalised anxiety disorder

1.0

Hypochondriacal disorders

0.9

Mixed anxiety and depressive disorder

1.2

Obsessive-compulsive disorder

0.9

Other anxiety or stress related disorder

1.2

Panic disorder [episodic paroxysmal anxiety]

0.9

Post-traumatic stress disorder

1.1

Social phobias

0.9

Specific (isolated) phobias

0.8

The mean ES in the above table is 1, this means that at the end of treatment the average client is better than 84% of those at the start. But it is not known how long this change lasts or what proportion of clients would consider themselves back to their old self. No independent person has asked them. The results are based on questionnaire responses made in the presence of the Santa like therapist. Who wants to displease Santa?

Science Has Progressed By Categorisation but IAPT Feigns This

The IAPT Manual states  that its’ staff do not make diagnoses. How then are the IAPT staff supposed to know which label to attach to whom? It can be contended that the diagnostic labels don’t matter, but that is not what NICE says, they recommend specific protocols for particular disorders. IAPT has been dishonest since its’ inception, in claiming NICE compliance. It should publicly admit that its staff excercise unbridled clinical judgement in choosing a ‘diagnostic’ label. As a consequence the treatment it serves up is necessarily idiosyncratic. There is know knowing what this Santa will deliver!

IAPT squeezes its clients into 12 categories, one of which mixed anxiety and depressive disorder is still used despite the advice in the 2019 Manual. No room at the inn for those with an adjustment disorder, personality disorder, bulimia, substance dependence, bipolar or psychosis. The injunction from the Service is to treat the principal disorder, but comorbidity is the rule rather than the exception. The implication is that comorbidity is best ignored. Clients are made to fit the Service and not the other way round.  

The Demise of The Supposed Medical Model and The Rise of Autocracy

There are many who see the ‘medical model’ as totally anathema and who should therefore be rejoicing at the de facto ignoring of diagnosis in IAPT. But they do so under their breath, as the prime movers in the development of the IAPT service, based their reputations on the efficacy of specific protocols for particular disorders e.g panic disorder.

 

The IAPT service is actually an experiment in determining what happens to clients if clinicians have free reign to treat clients as they see fit. The results of this clinician autocracy (or oligarchy if those who hold sway in IAPT/BABCP are considered) is that clients do not improve by any more than would be expected with the passage of time and attention.

The successors to Clinical Commissioning Groups make decisions locally as to how much money to invest in IAPT. But none have been prepared to open the ‘can of worms’ and insist that there is an independent assessor who at a minimum asks clients ‘compared to when you first went to IAPT are you the same, a little better, a little worse, much better, much worse? How long have you been the way you are now?

The Blatant Ignoring of Published Guidelines by IAPT

IAPT’s behaviour is in glaring contrast to that espoused in an Editorial in the most recent issue of the British Journal of Psychiatry who recommended observance of both NICE and Australian/New Zealand Guidelines for the treatment of depression  with ‘robust diagnosis and re-evaluation’ at the start of treatment and at 4-6 weeks, to check that the diagnosis is correct and redirect treatment if no response. They re-iterate that the Guidelines also state that if a person is unresponsive after 4-6 weeks there is ‘a need to address problems that may not seem to be directly pertinent to depression, such as personal, social or environmental factors, and advises that other illnesses (especially personality dysfunction) should also be considered as potential contributors to depression’. No such detailed re-evaluation ever takes place in IAPT, by their own admission they do not diagnose and certainly not personality disorders.

Dr Mike Scott

 

Dr Mike Scott