IAPT’s Sojourn Into The Quagmire

Putting patients with medically unexplained symptoms, such as CFS (chronic fatigue sundrome) and IBS (irritable bowel syndrone) on a mental health pathway, is a fraught endeavour, can there be any certainty that physical investigations of their difficulty will continue? Who will provide that certainty, surely not IAPT( Improving Access to Psychological Therapies) workers? Perhaps GP’s or gastroenterologists – doubtful?

 IAPT’s focus is on psychological interventions, most patients with long term physical conditions will find it incongruous to be offered a mental health intervention, unless there is a clear additional problem such as panic disorder. There is a danger that those with LTC’s will feel the normal emotional distress associated with their long standing problem is being psycho-pathologised.  

Whilst some with LTC’s may wish to avail themselves of psychological help, many will do so at the behest of a GP or gastronetrologist, believing that they would not be suggesting it, if it were not evidence based. Yet there is in fact a weak evidence base for CBT for these conditions compared to that which obtains for the anxiety disorders and depression.

Psychological interventions in the LTC area serve to distract from improving the poor quality services in areas in which CBT could make a real world difference. Rather they have a novelty value and attract funding/empire building.

Dr Mike Scott

Action Line Needed For Those Failed By Mental Health Services

It is 2 years since the Manchester Arena bombing, Cheryl has been absent from school since, despite 5 sessions of counselling at a well known Children’s Hospital. She and her Aunt (also a victim of the bombing) were invited to consider variously that Cheryl may be autistic, her difficulties may be a product of her mum’s childhood stressors, she may have PTSD and they need family therapy. All of which I found to be total rubbish.

The limited counselling she had only occurred because the Manchester Hub (set up to simply signpost people in the aftermath of the bombing) made regular contact with the Hospital. In fact all she was suffering from was panic disorder with agoraphobic avoidance and illness anxiety disorder. Within 2 sessions she has already made rapid progress.

Her aunt has had twelve sessions with an IAPT service followed by group therapy which she dropped out of. She was never offered any diagnosis. Two years on she is still struggling. Neither Cheryl or her Aunt have had anywhere significant to turn to to protest (the Hospital has made a half apology about being short staffed). But for both children and adults it is not just a question of money, the quality of service is woeful.

There is a pressing need for an action line for those failed by Mental Health Services.

Two years ago I wrote the book ‘Towards a Mental Health System That Works’ London, Routledge, the system is no better, just that some agencies are highly skilled at self-promotion and thereby expansion, MPs have been taken in by this and like to be seen to be on the side of mental health.

Dr Mike Scott

IAPT’s Clients – Vulnerable Adults With No Protection

Neither NHS England, Clinical Commissioning Groups or BABCP have taken any steps to ensure that there is independent monitoring of the welfare of IAPT’s clients. Such clients suffer a double whammy, not only do they experience the sense of helplessness often accompanying psychological debility, but they are also powerless to say anything about their experience.

The CONSORT guidelines ( see link below) state that randomised controlled trials should address outcomes that are meaningful to the patient. The same should apply to services delivered in routine practice. Changes in psychometric tests scores are not meaningful to clients, whereas no longer suffering from the disorder they were suffering from at the start of treatment is. But IAPT obfuscates its’ true performance by sleight of hand with psychometric test results. Clients are fodder for providing psychometric test data at each session, no matter that there is no certainty that the test is pertinent to what they are suffering, that repeated administration means that they can remember their last score and will want to convince themselves that they are getting better and that the results are interpreted by their therapist, creating a demand effect.

A major feature of the CONSORT guidelines is that treatment should be evaluated by those independent of service provision. There is no opportunity to protest about incompetence or the arbitrary number of session limit. IAPT violates this and every aspect of the guidelines that might be pertinent to routine practice.

Unfortunately Editors of Journals such as Behavioural and Cognitive Psychotherapy, Behaviour Research and Therapy and the Lancet often ignore the CONSORT guidelines or any translation of them into routine practice. Consequently the evidence base for expansion of IAPT into areas such as psychosis in secondary care, is much less than understood by its’ workers.

https://www.dropbox.com/s/vj2hp1q43hz4lh8/CONSORT%202010%20Explanation%20and%20Elaboration%20Document-BMJ.pdf?dl=0

Dr Mike Scott

In IAPT, CBT No Better Than Counselling

a study of IAPT data, by Barkham and Stone (2018), published in BMC Psychiatry, (see link below), shows high intensity CBT is no better than high intensity counselling. The authors note that this finding runs counter to NICE Guidance and they might have added to the specific superiority of CBT found for particular disorders, see Tolin et al (2015) [ link below]. This makes the whole IAPT database and its customary analysis suspect. Whatever the intervention Barkham and Stone (2018) found a 6 point reduction on the mean PHQ9 score of 15. Such a reduction one would expect with time and any ‘credible’ attention treatment.

Interestingly the Barkham and Stone (2018) study found low intensity CBT did not enhance performance of any high intensity intervention. The case for low intensity interventions appears to be built on sand. There was no evidence in this study that there were meaningful distinctions between CBT and counselling (i.e no fidelity checks) and no evidence of fidelity to an evidence based treatment protocol. Fidelity checks are impossible without the reliable diagnosis IAPT eskews.

The Barkham and Stone (2018) study lays bare the many fault lines in IAPT, the tremors can be felt when will the earthquake occur?

https://www.dropbox.com/s/0smsyusnobi6tnm/IAPT%20Barkham%20and%20Saxon%202018%20dodo%20verdict.pdf?dl=0

https://www.dropbox.com/s/r3bja27takbicnc/Tolin%202015%20Dodo.pdf?dl=0

Dr Mike Scott

Antidepressant Prescribing Doubles Since Advent of IAPT

this makes it difficult to believe that GP’s see IAPT as a credible alternative to antidepressants. GP’s welcome the opportunity to refer depressed/anxious patients anywhere (including IAPT), as they get a breather from them, as they struggle to cope with the deluge of patients with physical problems.

On today’s Radio 4, The President of the Royal College of General Practitioners was sanguine about the increased prescribing, citing the benefits of antidepressants. But the evidence that they make a real world difference that lasts is questionable, see link below:

https://www.dropbox.com/s/yuh8kbg6q0vj7i7/antidepressants%202017%20Jakobsen%20qstng%20methodology%20for%20outcome.pdf?dl=0

No matter, a rep from the Royal College of Psychiatry (RCP), also on Radio 4 today responded to the doubling of antidepressants, in the last decade, by saying that they should not be the ‘go to’ response to psychological debility. He should perhaps have a chat with the RCGP President! He suggests that instead there should be increased funding for ‘talking therapies’. But he seems unaware that the main provider of talking therapies, IAPT, has never been subjected to independently funded evaluation. The RCP would not tolerate this for claims of the efficacy of a drug, why do they tolerate it for the effectiveness of IAPT? It seems that in the current zeitgeist, being in favour of talking therapies is on a par with being in favour of peace, no one can doubt its’ value. But my study of 90 clients going through IAPT evaluated with a standardised diagnostic interview suggests that only the tip of the iceberg recover, see link below:

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

Dr Mike Scott

Better Than CBT?

‘Metacognitive therapy (MCT) is a new evidence based psychotherapy that is proving to be more effective than than CBT’ so runs the advert in the April 2019 issue of the Psychologist, promoting an MCT Conference at the end of next month. Inspection of the referenced supporting literature indicates that there is just one, to be published study, by Adrian Wells et al, on Generalised Anxiety Disorder, suggesting MCT outperforming CBT. In MCT their is allegedly a 70-80% recovery rate compared to average 50% in CBT.

But great care has to be taken in evaluating efficacy studies, those relating to GAD are an exemplar. Studies conducted only by the originator of a therapy (Adrian) are necessarily suspect, there needs to be at least one independent study by researchers without an allegiance to the therapy and in which there is blind assessment of outcome using a standardised diagnostic interview. Further the results should include blind rater assessments not merely self-report. Whilst Adrian’s work has not yet cleared this hurdle, a methodologically rigorous analysis of the CBT for GAD studies paints a less convincing picture than most CBT devotees would imagine. A review of CBT for GAD studies by Zhu and colleagues, found just 12 studies as worthy of consideration and commented:

‘Despite having blinded rater, in half the the studies the main outcome depended on the self-rating….The overall risk of bias was considered high in 8 of the 12 studies. And using the rigorous GRADE criteria the overall level of evidence was classified as ‘moderate’, which indicates that further research could change the widely accepted conclusion about the effectiveness of CBT. Thus the results in favor of CBT are strong, but not definitive’. Dropbox link to full article below:

https://www.dropbox.com/s/cng09hehty9qo02/GAD%20Meta-analysis.pdf?dl=0

When it comes to studies of CBT for long term physical conditions, the evidence is much weaker than that for GAD which raises the interesting question of ‘why IAPT is treating long term physical conditions’. This very question is to be addressed by a Psychological Welbeing Practioner at an IAPT PWP Conference on June 26th. Interestingly the Workshop is titled ‘Step 2 Support for long term conditions’. But there is surely a gross mismatch between a low intensity intervention and a long term physical condition! It rather looks like distinction between low and high intensity interventions is being blurred, not before time. However a colleague of mine working in high intensity has been trained in treating LTC’s but is restricted to 6 sessions! Despite none of the efficacy studies in this area offering just 6 sessions, I am off to a home for the bewildered and bemused.

Dr Mike Scott

IAPT’s Training Of Therapist’s On Working With Long Term Physical Conditions Muddies The Waters on Efficacy

the evidence base that CBT works with the psychological sequelae of physical conditions is of a wholly different order to that for depression and anxiety disorders (the original remit of IAPT). As a consequence therapists entering this area could become quickly demoralised, increasing the already high rates of burnout. To my knowledge, there are no studies in the LTC area that a) compare the CBT treatment with an active credible attention control group and b) involve independent assessment by a person blind to treatment. Rather outcome assessments are entirely by self report measures such as the PHQ9 and GAD7 of dubious relevance to the destabilisation that can arise from having an LTC.

Training appears to focus on what the therapist should do and the needed competences. But therapists should be aware that these are largely expert consensus statements, the least credible type of evidence and not something derived from an established evidence base.

There are all sorts of minefields in this area not least the diagnostic confusion between say cancer and depression both result in tiredness, insomnia and loss of appetite. Yet training appears not to address this.

One is reminded of the adage ‘fools rush in where angels fear to tread’, is it enticement by empire building and the availability of funds?.

Dr Mike Scott

IAPT And The Abuse of Psychometric Tests

A person who consents to a psychometric test has a right to a full explanation of its purposes. I have not met an IAPT client who has been given such an explanation. IAPT employees see it as a requirement of the organisation for ‘audit’, but this is not an explanation. Informed consent means that it has to be explained what would be the consequences of not taking the test, this never happens. It is important that tests are only given that are relevant to the purposes of evaluation (not to do so probably breaches data protection legislation). But in administering say the PHQ-9 the IAPT worker does not know whether this is pertinent to whatever the client is suffering from e.g OCD or PTSD (as there is no reliable standardised diagnostic interview). Further the client isn’t informed of the purpose to which the test result will be put, e.g it will be used by IAPT in such a way that any positive change on it greater than 6 will be publicised as indicating the difference the Organisation makes. It is not explained that the PHQ-9 was developed with funding from Pfizer, the drug company who would clearly benefit from the overidentification of depression. Further the PHQ-9 was extracted from the Prime-MD interview, taken out of this context its’ meaning is questionable.

Psychologists wield power in IAPT, they know or at least should know about the appropriate use of psychometric tests e.g if they are administered weekly the person can remember their last response thus biasing scoring. If on their watch they are allowing others to misuse them then this may be a matter for the HCPC and for some also the University body that employs them. Psychologists and Universities can not be complicit in a Government Quango marketing itself.

Dr Mike Scott

IAPT – The Need For A Product Recall

In response to David Clark’s blog ‘IAPT at 10’ on the NHS England website, I wrote: ‘If NHS England invited the manufacturer of a pharmaceutical to review the growth and successes of its’ drug over the last decade eyebrows would be raised. Yet this is precisely what has happened in asking David Clark to comment on his baby (IAPT) with whom he has an ongoing commitment and financial arrangement. In terms of publication bias his piece is off the scale.

No Independent Replication

There has never been independent replication of IAPT’s claim to 50% recovery. My own work, which is wholly independent of IAPT and was published in the Journal of Health Psychology   last year (see link below)  suggests a 10% recovery rate.

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

Questionnaires Rather Than An Independently Administered Standardised Diagnostic Interview

IAPT relies on questionnaires completed by clients with the full knowledge of the treating clinician, introducing a ‘demand’ element into the proceedings. Further there is in IAPT’s procedures no way of knowing that the questionnaire/s are tapping the disorder/s that are germane to the client. 

No Evidence of An Added Value To IAPT When Compared With Findings Before Its’ Inception

The changes in questionnaire scores observed in IAPT clients are no different to those observed on self-report measures administered to clients going through counselling before the advent of IAPT. The Mullin (2006) findings (see link below) are the appropriate counterfactual and indicate no added value to IAPT.

https://www.dropbox.com/s/8a4qv5r13rotkyy/Appropriate%20Counterfactual%20Mullin%202006.pdf?dl=0

Clients present for therapy at their worst and some improvement with time would inevitably be visible on a questionnaire, IAPT has provided no evidence that clients given simply attention would not have shown the same changes to those observed.

The Jettisoning of Evaluation Guidelines

Entry into Pharmaceutical/Psychological Studies is governed by the administration of a standardised diagnostic interview. Outcome is determined by blind re-administration of the interview at the end of treatment and follow up. In line with this, an international team of Experts [Guidi et al (2018) see link below] have developed evaluation guidelines stipulating the need for blind independent assessment of psychological interventions. All IAPT generated studies have breached these guidelines.

https://www.dropbox.com/s/hizta38yqm4lfh3/Methodological%20Recommendations%20for%20Trials%20of%20Psychological%20Interventions.pdf?dl=0

Countries that do not look at psychological interventions through the lens of such evaluation guidelines will be taken in by IAPT’s marketing prowess. Unfortunately many such countries have shown such gullibility in the last decade.

Failure to Engage and Treat Clients

IAPT loudly proclaims the very large number of clients that it makes contact with but this is meaningless when their trajectory is considered. Half of those referred to or referring themselves to IAPT   have less than 2 treatment sessions.  The mean number of sessions attended for those who have 2 or more sessions is 6, there is no NICE approved treatment for a psychological disorder that requires just 6 sessions.  It is scarcely credible that IAPT is providing an evidence based treatment on any scale. There is an an independent re-analysis of the IAPT data in the link below

http://therapymeetsnumbers.com/is-iapt-too-big-to-fail/

A Failure of Governance

IAPT is essentially a QUANGO dependent on NHS England, and committed to expansion but without any observance of evaluation guidelines.  NHS England has taken IAPT’s claims at face value, as a consequence Clinical Commissioning Groups focus only on operational matter, numbers, waiting times etc with no focus on clinical matters in their interactions with IAPT. The National Audit Office conducted an inquiry into IAPT but has failed to publish its’ results. There has been a gross failure of governance by public bodies and their representatives.

Only The Voice Of IAPT’s Hierarchy Is Listened To

There has been no attempt by public bodies to independently seek the views of consumers of IAPT services. However an IAPT teacher, Jason Roscoe has publicly made a blistering attack on the service, see link below

https://www.dropbox.com/s/myz53dyn8zqhj13/Has%20IAPT%20become%20a%20bit%20like%20Frankenstein.docx?dl=0

He reflects ‘the gap between what the literature advises and what management allow seems to be widening leaving the patients as the ones who are being given sub-therapeutic, watered-down CBT’ and adds ‘The result? A revolving door where patients return in quick succession for multiple episodes of treatment with a different therapist each time…..not only this IAPT also seems to be making its own workers ill with reports of compassion fatigue and burnout not uncommon’.

The views of the 90 IAPT clients I examined were almost wholly negative and indicated the need to transform IAPT see link below

https://www.dropbox.com/s/zhr1fkg71aqvno0/Transforming%20IAPT.pdf?dl=0

IAPT The Need For Product Recall

There are such serious doubts about what IAPT has delivered over the last decade, that if it were a piece of machinery the product would have been recalled. A decade ago I wrote a book on how CBT can be delivered, with fidelity to evidence based treatment protocols, [Scott (2009) Simply Effective Cognitive Behaviour Therapy, London: Routledge], there is a pressing need to review such provision. In private communication with David Clark I have acknowledged that my approach would make the assessment process more costly. However the evidence of the past decade is that it is not possible to make a real world difference to client’s lives without closely following the procedures involved in randomised controlled trials of CBT. Departure from reliable assessment, diagnosis, advice/treatment results in a failure to translate efficacious treatments to routine practice’.

Unfortunately NHS England only permits upto 1000 character comments on their invited blogs, so essentially only the 1st paragraph of this blog will likely appear.

Dr Mike Scott

The Gagging of Discussion About IAPT Following ‘Has IAPT Become A Bit Like Frankenstein’s Monster?’

I have just put the following post on the rarely used BABCP Discussion Forum, CBT Cafe, the only sanctioned vehicle for such expression:

‘BABCP has effectively gagged discussion of IAPT by refusing correspondence about Jason’s article (and David Clark’s response) in CBT Today. The suggestion that the CBT Cafe is the appropriate place for the discussion is ludicrous, as the most responded to thread there is the ‘Cafe with little Discussion’, with only two responses to Jason’s article and 30 views in the week since publication. By contrast CBT Today is seen by the 10,000 membership! If you wanted to sideline discussion this was the perfect way to do it. It would have been bad enough if this was an editorial decision (but editorial freedom is important) but when it was decided by the President this raises serious issues. Interestingly the two responses to Jason’s article were critical of IAPT, but criticisms are almost only ever made anonymously, such are the high levels of fear amongst clinicians. BABCP has studiously failed to grasp the nettle about IAPT, fear pervades the Cafe, people are ducking under the table’.

Dr Mike Scott