Month: May 2024

Categories
l

‘The UK NHS Talking Therapies Fantasy’

was published on May 23rd 2024 by the Spanish Society for Clinical Psychology   in its’ inaugural journal, Psicología Clínica – it is my updated critique of  the Service. My hope is that it will make countries think twice about adopting the UK model. It was a focus of a 1000 strong gathering of the Society in Cadiz. My thanks to the Editor and staff of the Journal, I wish them well in their new endeavour.

 

In this paper I refute the following myths:

Myth 1 It’s a World Beater

Myth 2 50% Recovery Rate

Myth 3 Real World Lasting Changes

Myth 4 Appropriate for All-Comers

Myth 5 It Delivers Evidence-based Psychological Therapy

Myth 6 Low Intensity Interventions Are Effective

Myth 7 Monitoring Is at the Heart of NHS Talking Therapies

Myth 8 Formulation Is Sufficient, No Need for Diagnosis

Myth 9 It Works Having the Least Qualified Practitioners as Gatekeepers

Myth 10 Talking Therapy Is the Same as Psychological Therapy

Myth 11 It’s Fine that NHS Talking Therapies Has Only Ever Marked Its’Homework

Myth 12 It’s Better Than What Existed Before and Better Than Support – It’s Value for Money

 

Dr Mike Scott

Categories
l

A Decade of Digital CBT- Questionable Effectiveness and Advertising Standards Concerned

yet it is at the heart of NHS Talking Therapies, with 635,759 sessions of internet enabled therapy taking place in 2022-23.  Recently an Editorial in the American Journal of Psychiatry bemoaned the dirth of quality evidence in support of Digital Mental Health (DGMH). Nevertheless one of the sponsors of NHS Talking Therapies networking events, Silver Cloud is still proclaiming that its’ computerised CBT has ‘up to a 70% recovery rate’. It is registered in Ireland and The Irish Advertising Standards Authority told me on May 14th 2024 that they ‘have ongoing concerns that the recovery rate statistic continues to change’ and need to investigate and will revert back to me when the investigations are concluded.

 

A particular concern raised in the American Journal of Psychiatry is that a randomised controlled trial of a digital version of dialectical behaviour therapy (DBT) for suicidal clients vs waiting list found that those who underwent DBT did worse in terms of harming themselves or completed suicide. The Journal suggests that the best evidence for DGMH  comes from a randomised controlled trial of depressed and anxious patients in primary care, assigned to 16 weeks of CBT or treatment as usual. It was indeed the case that at the 4 and 8 week marker those in CBT were outperforming those on the waiting list but by the 12 and 16 week markers there was no difference in PHQ-9 and GAD-7 scores. These authors have engaged in spin to assert that there must be something beneficial about low intensity CBT. The spin is even more in evidence when the authors fail to mention that the comparison for CBT was a waiting list (people don’t expect to improve on a waiting list) rather than a credible attention control condition. It is a striking example of poor methodology. Even these authors appear to operate with a heuristic that ‘there must be something good about low intensity CBT’.

Dr Mike Scott 

Categories
l

NHS Talking Therapies Claim To Parity Of Effectiveness With Clinical Trials – Fantastic Marketing, But Totally Bogus

The Service has never been evaluated with the rigour, comparable to that employed in randomised controlled trials i.e using blind independent assessors. NHS Talking Therapies has only ever marked its’ own homework. To compound matters further it has only taken a PHQ-9/ GAD-7 snapshot of  the person at their last contact with the Service. With nothing to indicate the duration of any gain or whether the change on these measures is clinically meaningful. 

Despite this the Service’s Manual cautions:

‘most referrals to NHS talking therapies will have elevated scores on the PHQ-9 nine and GAD-7. But this does not necessarily mean that they are suffering from clinical depression or generalised anxiety disorder. Unless the assessment process for all the NHS talking therapy relevant conditions, there is a risk that people will be started on the wrong treatment”

But the Manual also states that the Service treats 11 conditions and excludes 4 from its remit. Thus we are invited to believe that its clinicians screen for 15 conditions, but is silent on the mechanism by which this is achieved!  The assessors are for the most part by the least qualified (Psychological Wellbeing Practitioners). It is simply not credible that they have wherewithal to conduct such a comprehensive assessment and conduct it on the telephone, in the at most 1 hour assessment. 

The Service digs a deeper whole for itself when the Manual states ‘Focused supervision that starts by looking at the patient questionnaire scores and any changes on these’. The Tests are completed at every session. Clinicians can be called to task for not reaching a 50% recovery ate on the measures. Clearly the two questionnaires are expected to be central to the sessions leaving  little space for the alleged comprehensive screening. The authors of the Manual clearly suspect that things are going badly awry with treatments but their response is akin to that of the Post Office hierarchy with regard to sub-postmasters.

Dr Mike Scott

 

Categories
l

The NHS Talking Therapies Pathway – ridden with potholes

 

The latest data from the Service shows that in 2022-23, of those at the start of the pathway, 1.76 million, a third (31%) decided that this route was not for them and they did not move beyond an initial contact. Of the 1.22 million who had an assessment, half (44.9%) did not go beyond this one session. Thus, the first two potholes are of a comparable size (i.e the proportion defaulting).

Treatment (defined by the Service as people attending two or more sessions), follows a stepped care model, so that after the 1st two potholes you come to a fork, with 3 possible paths, shown in  Table 1 below, whichever one is taken the majority do not finish treatment

Table 1 Casualties in Stepped Care

 

Referrals finishing treatment

Percentage  referrals finishing

Mean number of sessions

Low intensity only

241,200

35.9

5.5

Both low and Hi intensity

262,063

39.0

10.3

Hi intensity therapy only

141.137

21.0

8.7

 

The potholes following the fork (i.e the proportion of people who default) are thus deeper than those before.

The pathway needs to be closed for repair and a diversion e.g attendance at a Citizens Advice Bureaux or local Charity,  needs to be put in place. There is no evidence travellers would be worse off. It would certainly cost a lot less than the £1 billion a year spent on Adult Mental Health Services in Primary Care.

 

Dr Mike Scott