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BABCP Response - NICE Consultation January 2022

NHS Talking Therapies – All Talk and No Added Value

The latest published studies of NHS Talking Therapies clients, Thew et al (2023) and Watkins et al (2023) offer no evidence that the interventions delivered are superior to a credible attention placebo condition. It beggars belief that: a) the National Audit Office has not investigated whether spending over £1bn on the Service is justified and b) it has evaded the scrutiny of the Care Quality Commission.

The authors of the Thew et al (2023) study suggest that the 6-week internet delivered CBT package for PTSD, is beneficial and may be deliverable by Psychological Wellbeing Practitioners. But there was no control condition. No diagnostic interview was conducted, there were no blind independent assessors and just 5 clients.

The primary outcome measure in the Thew et al (2023)  study was the PCL-5 but Bovin and Marx (2023) have pointed that reliance on this test leads to both a missing of those with a disorder and the unnecessary treatment of those without a disorder. Their findings were that cut-offs varied with the particular population addressed and the prevalence of the disorder in the particular community. Without attention to these details, clients will be misdirected. Bovin and Marx (2023) suggest that the PCL-5 should only be used as an adjunct to a diagnostic interview (but NHS Talking Therapies clients do not make diagnoses) and should involve a discussion with the client as to the meaning of each item. Given that NHS Talking Therapy clinicians  have to achieve a 50% recovery rate their ‘discussions’ on the PCL-5 are likely to be particularly biased. 

The Watkins et al (2023) study focuses on internet CBT for depression. They repeat the NHS Talking Therapies mantra of a 50% recovery rate for their intervention, but made no comparison with a credible attention control condition. But they claim to have used the depression module of the SCID for diagnosis but present no results on this pre or post treatment.  Whether or not, the SCID was not intended for use with a pre-determined module.

NHS Talking Therapy studies are de facto spin for the organisation. Researchers delight in the ease with which they can access subjects from it. Well-meaning people want to believe their efforts have not been in vain and this trumps seriously listening to those affected.

What the CQC would discover

If the CQC bothered to investigate they would discover a revolving door.

Recently I saw a lady who had had an accident at work. She was distressed at being physically unable to return to the job. This lady had 12 sessions with IAPT (NHS Talking Therapies predecessor) she found the therapist very understanding. But she couldn’t identify what she had learnt and said she was given no diagnosis. At the end of the sessions she was told she could re-refer if she needed to, which she did. The new male therapist seemed uninterested, and after 10 mins or so was  making an appointment for a further session. She dropped out but returned to IAPT with a new male therapists, sessions were similarly very brief and she found him ‘ignorant’ in that in the video link he would disappear from the screen, and she could hear him busy in the kitchen. Again she dropped out. She had unidentified and untreated mild  PTSD and depression from the accident.

If that hasn’t been a waste of the taxpayer’s money I don’t know what is.

 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

‘It’s Complex’

In mental health, the notion of complexity serves as a ‘get out of jail’ card for clinicians. But at the same time it decreases the clinicians sense of self-efficacy, placing them on a pathway to burnout. Clients are likely to be aghast, that they are a ‘complex case’, adding further to their demoralisation. ‘Complexity’ offers training bodies a new vehicle through which to market their wares.  With naïve clinicians scampering to sign up for workshops.

The notion of Complex PTSD was rejected by the DSM-5 Committee on the grounds that it had no added value over a PTSD diagnosis. The DSM-5-TR criteria include a trauma related , sense of  disconnection from others, beyond just being ‘out of sync’ and it can be specified whether the PTSD is with or without dissociative symptoms. There is thus no obvious added value in the Complex PTSD diagnosis. ICD  has always been a much looser categorisation of mental disorders and it is no surprise that Complex PTSD has found its way into the World Health Organisations missive. But there is no compelling clinical evidence of the distillation of a more potent therapeutic intervention. Jay (2023) in Mad In America describes some of the harms that she believes arise from the idea of Complex PTSD.

Personalising Treatment

In my book Personalising Trauma Treatment: Reframing and Reimagining published last year by London: Routledge, I quite deliberately did not use the construct of Complex PTSD. Nor have I used it in the writing of the 2nd Edition of my self-help book Moving on After Trauma London: Routledge (In Press). But in the clinical book I do give an example of helping a client who had laboured for over 20 years under the mistaken belief that he had PTSD as a result of child abuse. Treatment based on the PTSD descriptor had been wholly ineffective.  Using the the SCID standardised semi-structured interview which begins with an open-ended interview I made a diagnosis of borderline personality disorder (BPD). I explained to him that BPD is a historical term and that I believed that it did not mean that he could not recover from this and he was perfectly happy with this. In the treatment the focus was on what he took the abuse to mean about today and he fully recovered and has remained so 4 years post treatment.

The above example illustrates that the use of diagnosis does not mean that treatment is not personalised. However in general, in routine practice those who make diagnoses actually operate using their own prototype of a disorder and they match the person before them to this prototype. This has the advantage of speed but it also introduces biases about the importance of one symptom over another e.g in PTSD nightmares trumping disconnection, and biases about the typicality of the person seen by the clinician e.g working in an in-patient setting . This makes their diagnoses no more useful than the judgements of clinicians who eschew diagnoses.Science is about categorisation, diagnosis is quintessentially about categorisation. Though one can argue about the best forms of categorisation,  without diagnosis there is a lack of clarity what problem is being addressed. Clinicians then have have carte blanche to exercise their own unfettered clinical judgement. Operating like a ship without a rudder.

This is no academic matter, I have just  been talking to a GP about a patient of hers who has been treated by NHS Talking Therapies with EMDR. The patient had been bullied at work and was finding the EMDR ineffectual. The GP asked my opinion, I suggested that the patient would likely drop out because of the toxic trauma focus. Further a) EMDR is only NICE approved for PTSD, NHS Talking Therapies do not make diagnoses b) the stressor bullying would not meet the gateway stressor for PTSD in DSM-5. The GP concurred that the whole treatment approach was likely nonsense and that it was unlikely that the neurobiological pathways activated in bullying were the same as those activated by a terrorist bombing. Yet a further instance of NHS Talking Therapies talking through its’ hat.

But I do agree that the evidence base for the standard treatments for BPD is wanting, it is impossible from the studies to gauge what proportion of clients no longer suffer from BPD for what period. Albeit that there are claims for impact on suicidality.

It is not true that the diagnosis of BPD is unreliable, it has a perfectly acceptable kappa when a clinician blindly assesses a recording of a standardised semi-structured interview with a person Lobbestael et al 2011  with a value of 0.91.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

Antidepressant Manufacturers Claim Independent Evidence of Effectiveness But From NHS Talking Therapies A Deafening Silence

This evening at 8.0pm, Panorama on BBC 1, looks at the debacle of antidepressants, with a quarter of people on them for 5 years. But the antidepressant manufacturer’s protest that there is independent evidence of the effectiveness of their product. However NHS Talking Therapies has ducked under the radar: they make no claim to independent scrutiny, they are not subject to Care Quality Commission inspection and there is not a single publicly funded, independent study of their effectiveness. The cost to the taxpayer of NHS Talking Therapies is over a £1billion a year. My own study of 90 clients going through the Service was that only the tip of the iceberg recover Scott (2018) I brought this to the attention of the BBC some years ago, but instead they chose to listen to the power holders in NHS Talking Therapies predecessor IAPT.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

NHS Talking Therapies’ Claim to Provide CBT

Homework is an essential component of CBT [ Kazantzis (2021) ]. NHS Talking Therapies has never provided any evidence of psychological therapists’ homework assignments. But the Service has been funded to the tune of £1 billion a year. It looks like there is a case to answer with regards to fraud, to say nothing of a failure of governance. NHS Talking Therapies has not done its’ homework.

NHS Talking Therapies scientific pretensions – it offers what for what? There is no clarity about what population the Service is addressing, the accepted mantra is that its clients are ‘anxious/depressed’. But as its’ clinicians do not make diagnosis, the nature and severity of disorders is unknown. No fidelity checks have ever been employed, so it is not known whether the ‘alleged CBT’ actually happens. The scientific endeavour involves reliable categorisation, this is conspicuous by its’ absence in NHS Talking Therapies. It may be an expensive Quack remedy that the power holders are too embarrassed to acknowledge. But what is criminal is not to mount an independent investigation of the matter.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

NHS Talking Therapies – No Better Than GP Care

 

So why is the UK Government spending a £1 billion a year on NHS Talking therapies? NHS Talking Therapies raison d’etre is that it has a 50% recovery rate [IAPT Manual (2019)], based principally, on a change of score on the PHQ-9 from above caseness, (a score of 10 or more) to below 10,  from 1st to last assessment. But in a study of a sample of GP patients  (n=100)    [ Gilbody et al (2015)] given usual care, 56% recovered within 4 months and 60 and 61% recovering by 12 and 24 months respectively, using the   PHQ-9 as the outcome metric. [Albeit that 13% accessed IAPT  (the predecessor of NHS Talking Therapies]. Similarly, Moore et al (2012) found 47% recovering within 3 months.  Whence the added value of NHS Talking Therapies?

 

The null hypothesis is that NHS Talking Therapies are no better than treatment as usual.  Funding of the Service cannot be justified without studies demonstrating the superiority of these interventions to a credible attention control condition. But no such studies have been forthcoming. NHS Talking Therapies Outcome studies have ignored the placebo response. Most recently, Strauss et al (2023) in a comparison of 2 forms of low intensity guided self-help, claiming the superiority of mindfulness guided self-help  over CBT guided self-help, despite reductions in mean PHQ-9 scores from 14-15 to 6-7  in 16 weeks in both arms of the study. No mention that similar results would likely be obtained with an attention placebo, nor comment that 25% dropped out of each form of self-help.   Instead, Strauss et al (2023)  call for an expansion of guided self-help beyond the 100,000 current recipients a year, preferably mindful because it was cheaper!

The Size of The Placebo Response

 In a review by Motta et al (2023) the average response and remission rates in placebo groups (across all anxiety disorders including PTSD and OCD) were 37% and 24% respectively.  [Motta LS, Gosmann NP, Costa MdA, et al. BMJ Ment Health 2023;26:1–8]. Those diagnosed with GAD and PTSD had larger placebo response estimates than those with PD, SAD and OCD. These figures were calculated by a within group Standardised Mean Difference, the average within subject placebo effect size was -1.1. By comparison the mean average placebo effect size in depression is 0.37. [Furukawa TA, Cipriani A, Atkinson LZ, et al.2016:3:1059-66} Placebo response rates in antidepressant trials: a systematic review of published and unpublished double-blind randomised controlled studies Lancet Psychiatry 2016;3:1059–66].

Recovery in NHS Talking Therapies

The service claims a 50% recovery rate but I found that only the tip of the iceberg recover, Scott (2018). My finding is consistent with the reported recovery rates in the above placebo studies, given that the NHS Talking Therapies population is most likely a mix of people suffering predominantly anxiety or depression.

The burden of proof is on NHS Talking Therapies to demonstrate that it produces a clinically relevant effects beyond placebo. But I do not think it will attempt this anytime soon, it would be like turkeys voting for Christmas. 

Dr Mike Scott