Month: April 2023

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The Scientific Credibility Of NHS Talking Therapies

Taxonomy is at the heart of the scientific enterprise, different  treatments, for different phenomenon. But NHS Talking Therapies applies no reliable categorisation of patient difficulties. The Service thus lacks scientific credibility. 

But where is the public accountability? We rightly insist that schools are independently evaluated (Ofsted) so that parents know what they can expect from their child’s attendance at a particular school.We are concerned at any possible failings in the inspection body, with a recent recommendation that it ought to be complemented with another body the Care Quality Commission (CQC). However for the biggest provider of psychological treatment, NHS Talking therapies there is no independent inspection at all. Are those seeking help with mental health difficulties less important than children?

 

There is at least a case to answer with NHS Talking Therapies. Drew et al (2021 ) have demonstrated the factory-like quality of NHS Talking Therapies.De facto the therapists on the production line are given carte blanche to do what they want, provided the necessary paperwork, PH-9, GAD-7 and ICD-10 codes are completed. Should we as a Society be buying these wares at a cost of £750 million per year?

 

Most of what makes us human: consciousness, morals, values, meaning is outside the cause and effect world of science. Without an infusion from this level, psychological therapy is reduced to a production line. This applies not only to the ministrations of the therapists but also to those with responsibility for the Service, ultimately the NHS and politicians. Lip service is paid to a duty of care.

 

Dr Mike Scott

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Diagnostic Stewardship’s Abscence from NHS Talking Therapies

Diagnostic error occurs when a diagnosis is missed, inaccurate, imprecise, or incomplete.1 Diagnostic stewardship reduces diagnostic error primarily by reducing misdiagnosis. NHS Talking Therapies use problem descriptors, as a surrogate for diagnosis, and on this basis choose an ICD-10 code, but nowhere else in the NHS operates like this. Neither the validity or reliability of ICD-10 codes, established by these means, has been established. It is no more reliable than establishing a code based on the way the wind is blowing. The purpose of such a charade is to give NHS Talking Therapies a spurious scientific legitimacy. It is akin to a candidate for a post over-selling themselves at interview. It is tempting in such circumstance to blame the ‘candidate’, but the real problem is the interviewing panel ( Integrated Care Boards, politicians) all with their own agendas. These include being seen to do something that is immediately credible to the public, such as increase access, shorten waiting times. Achieving these goals maintains their position.

NHS Talking Therapies engages in further posing when it claims its’ therapists intervention are NICE compliant. Given that the services clinicians do not make diagnosis and that the treatments recommended by NICE are largely diagnosis specific, this is logically impossible. But by clever marketing and a strenuous avoidance of independent evaluation, NHS Talking Therapies perpetuates the myth. This is coupled with a phobic avoidance of discussion in the public domain. Preference is given to internal networking meetings of ‘best practice’ in which the agenda is set by the power holders in NHS Talking Therapies. Lessons in this are on offer from all totalitarian states, the only ones that pay are the subjects/clients.

The totalitarians are unwittingly helped by those who totally eskew diagnosis. The latter ‘free spirits’ have no metric with which to invalidate the claims of the totalitarians. It becomes a free for all of assertion and counter assertion, with no methodology that might lead to agreement. The primacy given to an individual therapists subjective formulation of a client’s difficulties can be easily dismissed on the grounds that it is idiosyncratic. In such circumstances the therapist’s bottom line amounts to ‘I want my autonomy at all costs, any infringement is coercion, deserving of my righteous wrath’ and an ignoring of the bigger picture.

Dr Mike Scott

Dr Mike Scott

Dr Mike Scott

1. Balogh  E, Miller  BT, Ball  J; Institute of Medicine.  Improving Diagnosis in Health Care. National Academies Press; 2015.

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Piracy in NHS Talking Therapies

The initial press-ganging of patients is conducted by a Psychological Wellbeing Practitioner (PWP). He/she is the least qualified member of staff. Nevertheless, the PWP determines the ‘vessel’ on which the patient is put. At best, the patient can vote with their feet. There is no indication of the ‘soundness’ of the vessel for them.

Here is an extract from a letter to the GP following an initial assessment by a PWP:

‘The difficulties as described at assessment appear consistent with PTSD although this is a description of symptoms and should not be considered a diagnosis’

Nevertheless, the PWP specifies an ICD-10 code for PTSD. Following the 40-minute telephone assessment this patient has 3 sessions of low intensity group treatment. The trauma in this case was a physically threatening altercation at work. But inspection of the DSM-5-TR stressor criteria for PTSD states that only an extreme trauma is the gateway to PTSD and that it is ‘extreme’ in that it is sudden and catastrophic Noorholm et al 2021. The PWP’s idiosyncratic use of diagnostic criteria is precisely what is condemned in DSM-5-TR (2022) P23 ‘lack of familiarity with DSM-5 or excessive, flexible and idiosyncratic application of DSM-5 criteria substantially reduces its utility as a common language for communication’. Noorholm et al 2021 also point out that the DSM-5 stressor criteria should be established using a standardised diagnostic interview and not be based on a self -report measure alone.  The PWP used a PTSD self-report measure on most occasions, and followed NHS Talking Therapies customary practice of routinely using the PHQ-9 and GAD-7.

Notwithstanding the above considerations there is no evidence that 3 sessions of group therapy makes a real-world difference to a person with PTSD. It is not an appropriate vessel for them to be put on. There is no evidence that the PWP or patient was aware of this. The patient is a victim of traffickers/organisational dictate. Informed consent is notable by its’ absence.

The patient is then switched ‘vessel’, with group sessions followed by 5 individual high intensity sessions of CBT. But there is no evidence that this dose of CBT makes a real-world difference to patients with PTSD – journeying once again on an ‘unsound vessel’. Unsurprisingly the high intensity therapists decides to switch the patient again to another ‘vessel’, EMDR. The patient then has 13 sessions of this, involving re-living of the altercation. But EMDR is only a NICE approved treatment for PTSD. The patient has had extensive inappropriate treatment. At the final session the female patient reports that the ‘memories …. don’t bother me much anymore’. But the avowed purpose of EMDR is to achieve such a response, the patient would feel that they were failing the therapist and themselves not to report such an improvement – the demand characteristics of therapy. Similarly changes on the PHQ-9 and GAD-7 could also reflect the demand characteristics and/or simply the passage of time.

A more plausible explanation of the patient’s difficulties was that they suffered a chronic adjustment disorder that would be in place until the employer ensured the safety of the patient. The extensive treatment has involved a psychopathologizing of the patient’s difficulties. It has also been a massive waste of psychological therapy resources. Assuming the high intensity therapy was costed at £100 per session the cost would be £1800. Assuming the group sessions cost £70 each the total cost would be £210 and the individual assessment by the PWP at say £80. The total cost of therapy would be £2000+.

The patient has been taken on an unnecessary and costly journey that could have been avoided with careful assessment, followed by watchful waiting. It is the public purse and patients that are the victims of this piracy.

Dr Mike Scott

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BMJ Mental Health and Bias

It is regrettable that BMJ Mental Health marks its transition from the Journal  Evidence-based Mental Health with the publication of a paper by O’Driscoll et al (2023) that obscures allegiance bias, by the authors simply declaring what grants they receive.  The authors work either for NHS trusts or IAPT, the former operate the latter. They use an IAPT dataset and uncritically utilise the services self-serving metric of recovery. These authors have not considered the Cochrane Risk of  Bias tool against which the study would have been judged as at high risk of bias. There is no acknowledgement of works that cast serious doubts on the Services claimed 50% recovery rate, Capobianco et al (2023), Scott (2018). 

 The O’Driscoll et al (2023) paper claims that CBT may be preferred  to counselling for clients who have anxiety symptoms comorbid with depression. But the conclusions are built on sand in that:

  1. there can be no certainty that the subjects studied were depressed as there was no ‘gold standard’ diagnostic interview conducted. Instead reliance was placed on a psychometric test, PHQ-9
  2.  there can be no certainty about comorbidity because of the absence of a diagnostic interview
  3. no fidelity checks were carried out to establish whether therapists were conducting CBT or counselling. Reliance was instead placed on therapists claims.
  4.  no blind-raters were used to assess outcome
  5. there can be no certainty that the observed changes would not have happened anyway because of the absence of a credible attention control condition
  6. there can be no certainty that the observed changes were clinically meaningful or that changes endured. A 6 point improvement in the CBT group and a 5 point improvement in the counselling for depression group on the PHQ-9.
  7. the study was restricted to patients who attended 5 or more treatment sessions, but these are unrepresentative of IAPT clients. Only half of clients have 2 or more treatment sessions (defined by IAPT as ‘treatment’). The mean number of IAPT treatment sessions is 7 but the mean number of treatment sessions in the O’Driscoll et al (2023) study was 10 in counselling for depression and 11 in CBT. Further the third of IAPT clients who undergo low intensity intervention alone were excluded. Generalisation from this study is fraught with difficulties

Does the emergence of BMJ Mental Health signal the demise of evidence-based mental health? I hope not.

Capobianco, L., Verbist, I., Heal, C., Huey, D., & Wells, A. (2023). Improving access to psychological therapies: Analysis of effects associated with remote provision during COVID-19. The British journal of clinical psychology, 62(1), 312–324. https://doi.org/10.1111/bjc.12410

 

 

O’Driscoll C, Buckman JEJ, Saunders R, et al Symptom-specific effects of counselling for depression compared to cognitive–behavioural therapy BMJ Ment Health 2023;26:e300621.

 

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/10.1177/1359105318755264