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NHS Talking Therapies Undue Deference to Two Psychometric Tests Stymies Listening and Treatment

 

Two psychometric tests, the PHQ-9 for depression and the GAD-7 for generalised anxiety disorder, are the twin pillars used by NHS Talking Therapies [formerly Improving Access to Psychological Therapies (IAPT)] service to direct therapy and evaluate outcome. The pillars form a gate through which the client is expected to pass, at every treatment session. Thus, making less time for listening to and treating clients.  

NHS Talking Therapies clinicians are not trained to make diagnoses, so the tests are the sole arbiter of the services effectiveness. I made a freedom of Information Request to NHS England requesting  details of the experience of clinicians and cost of the Service, bizarrely they said that they  did not have this information. Drawing on data from the rest of mental health services, it seems likely that most practitioners are less than 3 years in post, over 80% are female and most age 40 or below.   It stretches credibility to believe that these practitioners are sufficiently competent or diverse for the public they serve.

 

 Unfortunately, other agencies such as the Charity, Anxiety UK have felt compelled to adopt IAPT’s metrics. The result is chaos, when viewed through the lens of the recent Negeri et al (2021) meta-analysis of the accuracy of the PHQ-9 to assess for depression. A chaos which is compounded by looking through the other lens, of the accuracy of the GAD-7 in different settings.

The Misuse of the PHQ-9

Negeri et al (2021) provide a tool to indicate the likely consequences of use of the PHQ-9 by itself. The first step is to enter the likely prevalence of depression in the target population (in primary care they suggest it is likely to be 5-10% and in specialty care settings or those with chronic health conditions it is likely to be 10 to 20%). Entering a prevalence of 10% for the level of depression in those presenting to IAPT (using the standard cut-off of a score of 10+) 22% of client i.e 22 out of 100  would screen positive. Of the 22 9 (39%) would meet diagnostic criteria for major depression (true positives) 13 (61%) would not meet diagnostic croiteria for major depression ( false postives). Thus inappropriate treatment would be given to more than 1 out of 2 clients. Alternatively inputting a prevalence of 15% ( perhaps more accurate if the population included those with long term conditions) would give a prevalence rate of 26% i.e 26 out of 100.. Of the 26 13 (50%) would meet diagnostic criteria for major depression (true positives) but 13 (50%) would not meet diagnostic criteria for major depression (false positives). Thus, one out of two clients would be treated for depression when they did not need to be.

Using the PHQ-9, as often as not, IAPT’s clinicians are treating the wrong disorder. How then can the results ( a claimed 50% recovery rate) be comparable to that in the randomised controlled trials for depression where all the clients were known (on the basis of a ‘gold standard interview’) to be suffering from depression?

The Use of the GAD-7 By Agencies in Addition to the PHQ-9, Adds To the Misdirection and Makes Their Claims of Effectiveness Even Less Credible

Rutter and Brown (2016) concluded that the GAD-7 is ‘a dimensional indicator of GAD severity rather than a screening tool for the presence or absence of the disorder in outpatients with anxiety and mood disorders’ and the GAD-7 did not provide sufficient specific information to indicate the presence of a GAD diagnosis’, At a cut-off of 10 the sensitivity was 79.5% and specificity 44.7%. Using a cut off of 8 the sensitivity was 86.5% but the specificity was 34.8%. But In the validation study of the GAD-7 by Spitzer et al (2006) the optimal cut off was a score of 10 or more, 89% with GAD had GAD-7 scores of 10 or greater (sensitivity ), whereas most patients 82% without GAD had scores less than 10 (specificity). The psychometric properties of the GAD-7 have also been examined in a heterogeneous sample of different diagnoses. Beard and Björgvinsson (2014) found poor specificity and a high false positive rate for specific anxiety disorders and the proposed cutoff by Spitzer et al. (2006) of ≥10 was only partly supported with a sensitivity of 74% and specificity of 54%. Kroenke et al. (2007) found that the GAD-7 performed well as a screener for GAD, post-traumatic stress disorder (PTSD), social anxiety disorder (SAD), and panic disorder (PD) in primary care patients and proposed a score of 8 as a cutoff score with a positive likelihood ratio above 3. It appears that it is only the authors of the GAD-7 that claim its value.

 

Getting Real

The most plausible explanation is that IAPT has engaged in self-promotion. Realistically, only the tip of the iceberg of IAPT clients recover Scott (2018).

But it is not only IAPT who are making false claims so to are other service providers. There is pressing need for independent audit using ‘gold standard’ assessments of the trajectory of clients lives after treatment.

 

Beard, C., and Björgvinsson, T. (2014). Beyond generalized anxiety disorder: psychometric properties of the GAD-7 in a heterogeneous psychiatric sample. J. Anxiety Disord. 28, 547–552. doi: 10.1016/j.janxdis.2014.06.002

Kroenke, K., Spitzer, R. L., Williams, J. B. W., Monahan, P. O., and Löwe, B. (2007). Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann. Intern. Med. 146, 317–325. doi: 10.7326/0003-4819-146-5- 200703060- 00004

Rutter, L. A., and Brown, T. A. (2017). Psychometric properties of the generalized  anxiety disorder scale-7 (GAD-7) in outpatients with anxiety and mood disorders. J. Psychopathol. Behav. Assess. 39, 140–146. doi: 10.1007/s10862-016- 9571- 9

 

Spitzer, R. L., Kroenke, K., Williams, J. B. W., and Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder the GAD-7. Arch. Intern. Med. 166, 1092–1097. doi: 10.1001/archinte.166.10.1092

 

 

Dr Mike Scott

 

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NHS Talking Therapies the Victory of ‘Satisficing’ Over What Clients Really Want 

 

Satisficing is a term used by economists to denote a decision-making strategy or cognitive heuristic that involves searching through alternatives until an option is considered to clear an acceptability threshold. The Labour Party Economist, Lord Layard considered that with the help of psychologist, Professor David Clark, they could make a sufficiently plausible case to Government to fund the Improving Access to Psychological Therapy (IAPT) service [now rebranded NHS Talking Therapies for anxiety and depression]. In this they were successful [‘Thrive’ Layard and Clark (2014)]. The new Labour Government shows no sign of wanting to review its’ received mantra, despite a cost £2 billion a year for Adult and Child mental health services. But the voice of mental health sufferers has been nowhere in evidence. There was no evidence that the proposed mode of service delivery would result in recovery, in a way that was intelligible to sufferers, such as no longer suffering from a disorder for a significant period of time.

In the 2011 book by Psychologist, Martin Seligman ‘Flourish’, Layard chides him  “You, like most academic types, have a superstition about the relation of public policy to evidence. You probably think that Parliament adopts a program when the scientific evidence mounts and mounts, up to a point that it is compelling, irresistible. In my whole political life, I have never seen a single example of this. Science makes it into public policy when the evidence is sufficient and the political will is present”.

But what if there are vested interests in determining what is ‘sufficient evidence’ ? For sixteen years the Service has continued to proclaim its’ 50% recovery rate, despite no independent evidence using a ‘gold standard’ diagnostic interview.

 

Heuristics have the advantage of speed, getting things done, but not necessarily well enough from the point of view of the consumer. ‘Satisficing’ is a powerholders judgement, imposing its’ will, blind to cient’s satisfaction but very attractive to other powerholders. With a ‘satisficing’ rationale Layard also announced his intention to bring ‘positive education’ to schools. There has been a psychopathologising of the young with diagnoses of ADHD or ASD seen as the gateway to services and a sought after explanation of difficulties. With little attention to alternative and often more credible explanations of difficulties. This is not to deny that there are those few who truly have ASD in the traditional sense of the term. In practice, there is a de facto absence of specialist reliable assessment for these conditions. The upshot is that a great many people are treated ‘as if’ they have these conditions and may self-diagnose these conditions. 

 

Seligman, Martin E. P.. Flourish . Nicholas Brealey Publishing. Kindle Edition. 2011

 

Dr Mike Scott

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NHS Talking Therapies Black Hole

Data is only publicly available on the 1 in 2 people who undergo treatment, those who have had just one assessment/treatment session have disappeared down a black hole for the past 16 years. This is hardly the transparent and comprehensive monitoring of outcome claimed in the NHS Talking Therapies updated Manual.

But following a Freedom of Information request (FOI) I have obtained data on those attending only 1 session. But the diagnostic status of almost a third (29.1%) was unknown, making the Services claim to follow NICE approved diagnostic specific protocols meaningless. 

 


The Manual 5.1.3  recommends ‘systematic screening for all the conditions that NHS Talking Therapy treats’.  But there are 11 conditions that the Service treats.There is no evidence that at assessment its’ clinicians employ a standardised screen for the spectrum of disorders that they claim are within their remit to treat. Nor that they use a screen to rule out the disorders that they do not treat: personality disorder, psychosis, bipolar disorder and eating disorder. In the foreword to the Manual it states that those who do not go on to treatment are given ‘advice and signposting (if appropriate)’. But there is no clarity about the content of this ‘advice’ nor of its’ evidence base.  Signposting it seems may not occur, but this could plausibly be because the assessing clinician (usually the most junior member of staff- a Psychological Wellbeing Practitioner) simply doesn’t know the way.  One has a strong suspicion that those who have simply an ‘assessment’ disappear down a black hole, only to possibly re-emerge in desperation, when their difficulties have not resolved.

NHS Talking Therapies published data is at best consistent with passing improvement, for disorders that largely wax and wane anyway. 

Dr Mike Scott

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Something Is Very Amiss In Routine Care – There Is No Evidence of Translation From The Evidence-Based Psychological Treatments Of Randomised Controlled Trials

according to a meta-analysis in the Journal of Affective Disorders. This echoes my own finding of only a significant minority recovering in NHS Talking Therapies Scott (2018). The results are a far cry from the 50% recovery rate claimed by NHS Talking Therapies.

“It makes little sense to conduct hundreds of randomized trials on psychological treatments when they do not lead to better routine practice.” For those in care as usual only 1 in 6 or 7 recovered.When care as usual is persistently failing, the punters are clearly not being listened to.  It is like Stalinist Russia proclaiming another successful 5 year plan, when in reality the peasants are starving .

Where did it all go wrong?

Dr Mike Scott