Questions NHS England and IAPT Have Ignored Over Covid

 

How do you distinguish an adaptive reaction to Covid from a maladaptive one? Without answering this fundamental question NHS England has offered guidance….https://www.yourcovidrecovery.nhs.uk/managing-the-effects/effects-on-your-mind/managing-fear-and-anxiety/. on how psychological debility associated with having Covid might be managed. They offer a range of cognitive behavioural strategies commonly employed in the management of anxiety and depression. In addition they invite the public to complete a quiz, https://www.nhs.uk/conditions/stress-anxiety-depression/mood-self-assessment/ that actually comprises the questions in the PHQ-9 (that measures the severity of depression) and the GAD-7 (that measures the severity of generalised anxiety disorder), together with a question on the extent to which they feel impaired by these difficulties.

If the person scores highly on the quiz they are advised to see their GP and/or refer themselves to IAPT, as a diagnosis can only be made by professionals. But the IAPT Manual states IAPT therapists don’t make diagnosis, further they have no expertise with regards to a physical disorder.What then would an IAPT therapist be treating?

How meaningfully can a GP determine whether the fatigue associated with Covid should count towards a diagnosis of depression? Should the low mood associated with being ill count as a depressive symptom? Many Covid patients have breathing difficulties that can disturb sleep, should this insomnia count as a depression symptom? Loss of appetite is a common symptom of being ill, should it count as a symptom of depression? Should the worries of a Covid patient about the trajectory of their illness and occupational/financial impairment count as a symptom of anxiety?  With the exception of helping patients with Covid who are suicidal, psychologising Covid patients symptoms looks like an exercise in empire building.  

Whilst NHS England’s offering of the CBT strategies to members of the public might not be unreasonable, there is no evidence that these strategies taken out of the context in which they were developed make a real-world difference to those with a long term condition. Equally there is no evidence that such strategies delivered by IAPT practitoners makes a real world difference, the service has a recovery rate of 10% Scott (2018) https://doi.org/10.1177/1359105318755264

Are we to assume that those most debilitated by Covid, the likely most stressed, are the most in need of psychological intervention?

What body of knowledge do psychological therapists have that would make a real-world difference to the outcome of Covid in a particular instance?

 

Dr Mike Scott

Following NICE Guidance On Covid Treatment Threatens To Overwhelm Mental Health Services

Yesterday NICE issued guidance on the management of Covid post 12 weeks (long term) https://www.nice.org.uk/guidance/ng188 and recommends that those with mild anxiety or mild depression are referred to mental health services, with severe cases of anxiety/depression referred to psychiatrists. IAPT (Improving Access to Psychological Therapies) has already been conducting webinars for its’ Step 3 staff, within which concerns were expressed about possibly overwhelming services and the pathologising of normality. Despite this further webinars are planned for the low intensity (Step 2) staff. Buoyed by its’ success in attracting monies for psychological therapies for long-term conditions (LTCs), such as chronic pain, irritable bowel syndrome, IAPT sees an opportunity to extend its’ reach to those affected by Covid. Those with long term Covid are likely to suffer the same fate of those with Chronic Fatigue Syndrome of not being really listened to. 

Given that according to NICE the most common features of long term Covid are fatigue, ‘brain fog’ and breathlessness, and that ‘symptoms of anxiety and depression’  are presented as possible symptoms of Covid at any stage, how is it possible to make an additional diagnosis of anxiety and depression? With the exception of the few, Covid patients who may be suicidal the distinction between the physical and psychological symptoms is fraught with difficulties. One response is to ignore the distinction, ignore the science and claim that all with Covid need a psychological therapist, but there is no scientific evidence for this – albeit that it suits the purposes of service providers to make such a claim. If you were not feeling ‘mildly anxious or depressed’ when you contract Covid that is probably very worrying!

An editorial in the British Medical Journal http://dx.doi.org/10.1136/bmj.m4425 bemoans the medico-political contexts that has hampered scientists expressing their concerns over the evidence base for handling Covid. But such a medico-political context has operated for years with regard to IAPT. There has been no independent evidence that IAPT’s work with sufferer’s from LTC’s has led to the resolution of accompanying psychological disorders. There has been no comparison with an active placebo or with the fate of LTC sufferers before the advent of IAPT.  The National Audit Office was allowed to suspend its’ investigation of IAPT in 2017, with no check on the appropriateness of having spent £4 billion of the public purse on the Service. Matters have been compounded by the BABCP’s (the lead organisation for cbt) unwavering support for IAPT and the British Psychological Society’s endorsement of IAPT training. Despite any evidence that the competence of therapists trained relates to client outcome Liness et al (2019) https://www.dropbox.com/s/e26n191ie09sngs/Competence%20and%20Outcome%20IAPT%20no%20relation%202019.pdf?dl=0.

2021 can only get better, one needs hope, I think that this is the message of Christmas.

Dr Mike Scott

IAPT’s Black Hole – Accountability

I recently asked the National Audit Office to restart it’s investigation into IAPT. I am expecting their reply in the next week or two. There has been no independent scrutiny of IAPT. They have been answerable only to Clinical Commissioning Groups, which have consisted largely of GPs and allowed IAPT to mark its’ own homework.

But the accountability gap also extends downwards, where is the evidence that front line staff or clients have been consulted or involved in decision making?  Most recently IAPT has offered webinars, for its staff on helping those with long term COVID.   There is a tacit assumption that this will be within the expertise of IAPT therapists just as helping those with long term physical conditions such as irritable bowel syndrome. But the IAPT staff working with LTCs were never consulted, before this new foray. Client’s with LTCs were never asked whether they were back to their old selves (or best functioning) before this proposed further extension of IAPT’s empire.  

In the forthcoming issue of the British Journal of Clinical Psychology I have challenged IAPT’s account of its ‘performance’ see ‘Ensuring IAPT Does What It Says On The Tin’ https://doi.org/10.1111/bjc.12264. There is a reply in rebuttal see ‘The costs and benefits of practice-based evidence: correcting some misunderstandings about the 10-year meta-analysis of IAPT studies’ https://doi.org/10.1111/bjc.12268 that reveals a breathtaking level of conflict of interests. IAPT and its’ fellow travellers should be held to account. But importantly they also need to account to their therapists and clients. [ The original IAPT paper is available at https://doi.org/10.1111/bjc.12259]

 

Dr Mike Scott

IAPT, No Better Than Placebo?

There is no compelling evidence that the Improving Access to Psychological Therapies (IAPT) service is any better than a placebo, yet its’ expansion continues to be funded, despite £4 billion having already having been spent on it. Barkham and Saxon (2018) https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-018-1899-0  in their study of IAPT, found a within subjects  overall effect size of 0.93, amongst clients attending a mean of 6-9 treatment sessions. [Effect size is calculated by subtracting the mean post-treatment score from the mean pre-treatment score and dividing by the pooled pretreatment standard deviation]. But Huneke et al (2020) https://doi.org/10.1017/ S0033291720003633 cite placebo effect sizes of between 0.65 to 1.29 in anxiety disorder outcome studies. This raises serious doubts on the added value of IAPT.  They further note that approximately 30% of patients in antidepressant and antipsychotic trials respond to placebo treatment. Whilst Barkham and Saxon indicate that 50% of IAPT clients make a reliable and clinically significant improvement, adjusting this figure for differences in the severity of mental illness, likely produces a response rate not obviously different to that in IAPT. 

However the above considerations are not definitive, IAPT’s performance has never been compared with an active control condition, leaving the jury out on its’ performance. Unfortunately this has left IAPT free to drain the public purse at will. The ultimate disgrace is that the Government/Public Health England have not subjected IAPT to independent scrutiny. Such a position would not be tolerated with regards to a vaccine, but it is apparently ok to look the other way on mental health.

Dr Mike Scott

A Psychological Wellbeing Practitioner’s Damning Indictment of Her Role

Last week a PWP (Psychological Wellbeing Practitioner) ALIEE November 25th 2020 put a post on this blog, calling for Panorama to take note of the desperate plight of PWPs – the main providers of services in the Improving Access to Psychological Therapies (IAPT) Service. Unfortunately the track record of the media in this regard is not good. It is a year since Radio 4 chose to broadcast predominantly the voices of  lead figures in IAPT and well known fellow travellers, rather than give expression to those at the coalface  and their clients.   One wonders what it takes for the media to wake up and ‘smell the coffee’ – £4billion has been spent on IAPT over the last decade all without any independent audit. Given the current, parlous state of Government finances this should at least come under independent critical review, perhaps by the Office for Budget Responsibility.

When a PWP candidly admits “I am trained to overlook the full picture”, it raises eyebrows. Then when ALIEE goes on to say that she operates purely with the ‘5 area model’,  this is jaw dropping.  This is not a model for any psychological disorder, by itself it is a heuristic for providing generic cbt, which has never been considered an evidence-supported treatment. Then this PWP states if clients still have high PHQ9 and GAD7 scores by the 4th session, it is the client who should be interrogated for their  competence in scoring, with the threat that if such scores persist there is the spectre of criticism from superiors. This is tantamount to fiddling results. It is atrocious that AIEE has been placed in this invidious position. I do not believe she is weak but rather like a prisoner at Auschwitz charged with the removal of dead bodies from a gas chamber.

The burden of proof is with IAPT to demonstrate that it has procedures in place to make it impossible for ALIEE to have been operating in this way. Protestations that ‘there a few bad apples’ in every workforce simply won’t wash.

Getting the media and politicians to listen is like getting the post war German Government to take action against war criminals. Action was only finally taken following many years of work by children of Holocaust victims. Unfortunately in the short term the implicit plea is that ‘we have enough to do with the Pandemic and Brexit, not to say Climate Change’ but the climate of the upcoming generation is affected by the mental health of today’s adults. 

Dr Mike Scott

IAPT’s Hall of Mirrors Feedback

negates improved practice. The Organisation’s usage of the Patient Experience Questionnaire (PEQ) violates all the key requirements for eliciting feedback, which has to involve:

a) a response to questions that have an unambiguous real world meaning e.g ‘are you back to your old self  since treatment? i.e questions have to have validity

b) drawing upon a consecutive series of clients

c) completion anonymously and not in the presence of the therapist

d) a representative sample.

IAPT makes a token gesture of soliciting feedback using the Patients Experience questionnaire,  but its’ modus operandi is such that it cannot furnish a body of evidence that would demonstrate that it is not a ‘world beater’. In effect it has operated with a confirmatory bias only seeking information that would confirm its’ prior belief.

In 2016-2017, of 219 Clinical Commissioning Groups in England, 55 (25%) produced no PEQ data at all, i.e that a quarter of CCGs were funding a service in the absence of any evidence that the IAPT Service was eliciting feedback. In 2017-2018 of the 554,709 clients who completed a course of treatment  only 22% Moller et al (2019) https://doi.org/10.1186/s12888-019-2235-z completed the treatment questions on the PEQ.

There is no evidence that IAPT took active steps to ensure completion by consecutive cases or that therapists were blind to the results of the PEQ. The questions on the PEQ are themselves of doubtful validity e.g ‘how satisfied are you with your assessment’, this  question presupposes that the client has the knowledge base as to what constitutes a good assessment, imagine  if asked this question as a possible COVID patient most of us would believe ‘it is outside my expertise to judge the matter’. The question on the PEQ ‘on reflection, did you get the help that mattered to you’ is ambiguous, is it asking about the emotional significance of the encounter with the therapist, for example did they really listen/seem to care or about whether as a result of treatment you had returned to normal functioning.

Government and Clinical Commissioning Groups have turned a blind eye to IAPT’s failure to systematically elicit feedback from clients. At a cost of £4billion over the last decade and an incalcu cost to mental health. sufferers.

Dr Mike Scott

 

 

‘CBT Is Not A Treatment Or Cure for ME/CFS’

announced NICE in its’ draft guidance, https://t.co/OWJjzbQGqK?amp=1 on November 10th 2020. This is likely to come as a shock to Improving Access to Psychological Therapies (IAPT) Service clinicians charged with delivering treatment to patients with Medically Unexplained symptoms, a term which embraces chronic fatigue syndrome (CFS) sufferers, those with musculo- skeletal pain and those with irritable bowel syndrome.  Will the IAPT clinicians explain to CFS sufferers that they are not providing treatment, just helping them ‘manage their symptoms’ as NICE now recommends?.

Will they tell their client that they don’t know what the odds are that the programme will make them ‘manage their symptoms’ better?  

It will no longer be credible for IAPT workers to present the CBT model of MUS which posits that the latter is a product of an interaction of personality factors like perfectionism, illness beliefs (attributions), cognitions (catastrophising), and behaviours such as symptom focusing (somatising) and avoiding activity (due to fear-avoidance or anxiety), (albeit that biological factors are acknowledged but given no explanatory powers). If indeed this CBT model is at the core of the pathology underpinning CFS, then CBT treatments should have resolved the disorder and not simply have helped sufferers ‘manage their symptoms’.  

IAPT assesses the competence of its CFS clinicians, in part, by whether they explain the CBT model of MUS. They need an urgent rethink.  How many of its’ therapists have they stressed out by asking them to promulgate a model that doesn’t deserve the term. It is not surprising that when Keith Geraghty and I (2020) reviewed IAPT data doi: 10.1186/s40359-020-0380-2 we found that only 4.6% of the MUS patients IAPT taken into treatment, complete intensive CBT.

NICE have taken seriously the views of sufferers and the experiences of clinicians and have been unimpressed by the quality of studies on the effectiveness of CBT for CFS. Unfortunately consumer and clinicians views on CBT meted out in routine IAPT practice,  for supposedly depression and the anxiety disorders, have yet to be elicited and what we have been offered is research evidence that is far from compelling,  Scott (2020) https://doi.org/10.1111/bjc.12264. 

Professor Jonathan Edwards submission to the NICE guideline Committee are a must read he highlights the importance of support over treatment:

much more emphasis is needed on ongoing support, rather than the use of short treatment courses. Perhaps the greatest missed opportunity of trials focussing on stereotyped treatment modalities is a failure to recognise the value of support from experienced carers that simply aims to make life easier to cope with, rather than address a theoretical model’

His is a clarion call  for basic humanity, being with people rather than believing that everything is fixable, walking the road with them. This should not be put under a CBT umbrella, to do so is a gross imperialism. Professor Edwards strictures  on the research are exemplary:

 ‘all the studies that claim to show benefit from therapist-delivered treatments in ME/CFS are unblinded trials that make use of subjective outcome measures… ….unblinded trials with subjective outcomes are specifically considered unreliable’ 

He goes on to  detail why such methodological rigour is required such as finding that repeating an experiment with unblinded assessors has discredited the initial positive findings and the problems of not taking seriously allegiance bias and none declaration of conflicts of interest. professor Edwards addresses the issue of honesty thus on p10 of his submission:

Patients are entitled to be fully informed, based on reliable evidence. As I understand it, patients receiving CBT are not told that the explanation given for the illness is speculative, that there is no reliable evidence for the efficacy of the treatment or that objective measurements and long-term follow-up suggests there is none of consequence. Convincing the patient that the explanation of the illness is correct, and that the treatment is effective, appear to be inherent to the way CBT is supposed to work. It would therefore appear to be unethical to continue development and use of CBT based on the current approach of altering beliefs about e.g. disease causation or effects of exercise’.

But exactly the same critique can be applied to IAPT’s low intensity CBT interventions.

 

 

Dr Mike Scott

 

Spinning Low Intensity CBT and Treatments for Refugees

How seriously should we take claims for the efficacy of an intervention?  The ‘Risk of bias” assessment tool developed by the Cochrane Collaboration (2011), see slide, helps distinguish clever marketing from the genuine article. All LiCBT intervention studies fail the Tools requirement for the blinding of outcome assessment, suggesting a high risk of bias.  

In LiCBT studies, there are no independent assessments to determine whether those treated were no longer suffering  from the primary disorder for which they first presented.  LiCBT interventions is the most common treatment modality in the Improving Access to Psychological Therapies (IAPT) service.

But the LiCBT studies are not only subject to this detection bias, but in many instances they are also subject to allegiance bias, with the main author of the study evaluating their own manualised intervention e.g Williams et al (2018) evaluation of the Living Life To The Full Classes doi: 10.1192/bjp.2017.18

But the purveyors of LiCBT interventions do not have a monopoly on proclaiming effectiveness were non exists. A just published study by Kip et al (2020) DOI: 10.1002/cpp.2446 in Clinical Psychology and Psychotherapy  claims that ‘psychological interventions can effectively reduce symptoms of both PTSD and depression in adult refugees’. But of the 14 studies on adult refugees  only in 4 studies was outcome assessed by a ‘gold standard’ semi structured interview (the CAPS). The method of determining the diagnostic status of the refugees at entry to the study is unclear, but of the 9 questions asked to determine the quality of the included studies  the lowest score   was for whether the diagnosis was determined by using a semi structured interview. The next lowest score was for the item referring to fidelity checks i.e did the clients actually receive the treatment that it was purported they receive. Five out of six studies on Narrative Exposure Therapy  involved at least one author of the published manual on NET.  In total half of the trials researchers  were involved in utilising manuals whose development they were involved in. There is clearly a pressing need for independent replication of these findings on refugees. There is also a need to higher the methodological bar, as it is impossible to say from this review what proportion of refugees were no longer suffering from PTSD at the end of treatment, nor how long that improvement persisted.

Like IAPT the understandable wish to further dissemination takes precedence over a determination about whether treatment makes a real world difference to clients lives.

Dr Mike Scott

 

Mental Health Sufferers Vote With Their Feet and Government Does Nothing At All

 of those who undergo an initial assessment with the Improving Access to Psychological Therapies (IAPT) Service 40% do not go on to have treatment, and about the same proportion (42%) attend only one treatment session, according to a just published study by Davis A, Smith T, Talbot J, et al. Evid Based Ment Health 2020;23:8–14. doi:10.1136/ebmental-2019-300133. These findings echo a study  published last year by Moller et al (2019) https://doi.org/10.1186/s12888-019-2235-z, on a smaller sample, which suggested that 29% were non-starters and that the same proportion attended only one treatment session. Further scrutiny of the data reveals that about 3 out of 4 people drop out of treatment once begun. Unsurprisingly the authors’s independent study, of 90 IAPT clients, Scott (2018) revealed that only the tip of the iceberg (9.2%) recovered                 DOI: 10.1177/1359105318755264, raising serious questions about why the Government has spent over £4 billion on the service.

What Has Gone Wrong?

Kline et al (2020) consider that at an assessment by a clinician is supposed to: a) provide a credible rationale for the proposed treatment b)  detail the efficacy of the envisaged treatment and c) ensure that the clients preferences are acknowledged. IAPT’ assessments fail on all counts, taking these in turn:

a. If the problem is ill-defined e.g low mood/stress it is not clear what rationale should be presented. It is doubtful that a 30-45 minute telephone conversation can provide sufficient space to define the primary problem and other problems/disorders that may complicate treatment. Initial assessments  of patients for randomised controlled trials of psychological interventions are typically 90 mins plus, if this is the time deemed necessary to reliably diagnose a patient by a highly trained clinician, how can a much less trained PWP do it in less than half the time? Under time pressure a PWP may consider providing a credible rationale is part of treatment not assessment and in such circumstances it becomes more likely that a client will default. 

b. How often do PWPs present clients with evidence on the efficacy of an intervention? Take for example, computer assisted CBT, does the therapist tell the client that only 7 out of 48 of NHS recommended e-therapies have been subjected to randomised controlled trials, ( see Simmonds-buckley et al J Med Internet Res 2020;22(10):e17049) doi: 10.2196/170490 and even in these a gold standard semi-structured diagnostic interview conducted by a blind assessor was not use to determine diagnostic status post treatment, i.e there was no determination of the proportion of clients who were back to their old self after treatment and for how long. Further the e-therapies had average dropout rates of 31%.  They are not evidence based treatments in the way the NICE recommended high intensity treatments are. But approximately three quarters Of IAPT interventions (73%) are low intensity first, with 4% stepped up to high intensity and 20% in total receiving a high intensity intervention Davis A, Smith T, Talbot J, et al. Evid Based Ment Health 2020;23:8–14. doi:10.1136/ebmental-2019-300133

c. Client’s preferences are a predictor of engagement in treatment, but how often is a client given a choice between a low intensity intervention and a high intensity intervention. If both options are juxtaposed choice is likely skewed by informing the client that the high intensity intervention has a much longer waiting time.

Defining A Dropout

The generally accepted definition of a dropout is attending less than 7 sessions [see Kline et al (2020) https://doi.org/10.1016/j.brat.2020.103750], it is held that clients attending below this number will have had a sub-therapeutic dose of treatment and are therefore unlikely to respond]. Applying this metric to IAPT’s dataset is difficult as they only report data for those who complete 2 or more sessions and for which the average number of sessions attended is 6, thus the likely dropout rate from IAPT treatment, as most would understand the term, is about 75%.  But IAPT has developed its’ own definition of a completer as one who attends 2 or more sessions. This strange definition serves only to muddy the waters on its haemorrhaging of clients. It makes no sense to continue to fund IAPT without an independent  government inquiry into its’ modus operandi.

 

An Alternative Way Forward

Such has been the marketing power of IAPT over the last decade, that professional organisations such as the British Association for Behavioural and Cognitive Psychotherapies (BABCP) and the British Psychological Society (BPS) have sat mesmerised, as the Services fellow travellers have dominated accreditation and training.     In ‘Simply Effective Cognitive Behaviour Therapy’  published in (2009) by Routledge, I detailed a very different way of delivering services, that represents a faithful translation of the CBT treatments delivered in the randomised controlled trials (rcts) for depression and the anxiety disorders. Unfortunately it is IAPT’s fundamentalist translation of the rcts that has held sway and has brooked no debate either in journals or at Conferences.

 

Dr Mike Scott

 

Psychological Wellbeing Practitioners (PWPs) Ill-equipped, Yet On Sentry Duty

John, a client of mine,  had a telephone assessment by a PWP at the IAPT (Improving Access to Psychological Therapies) Service and was told that he might have bipolar disorder. IAPT referred him to Secondary care but without any indication of how long he would have to wait for an appointment, nor any indication of the possible consequences. Within minutes of talking to him it was apparent that he had never had an elevation of mood that lasted more than a day. Albeit, that on his best days he felt he could do anything, but others had never reported that his behaviour was strange or bizarre at those times. John did get low but not most of the day, most days.

The PWP hadn’t picked up at all that he was troubled by obsessive thoughts of engaging in embarrassing behaviour. John in fact had OCD but without overt ritualistic behaviour. It takes little imagination to realise that a client is likely to Google any suggestion that comes from clinician, making it wholly unacceptable to hint at severe mental illness without due care and attention. PWPs are simply not equipped for the purpose of guarding entry into the mental health services. Nor is there any credible evidence that they deliver evidence based treatment. 

Consider how PWPs operate, armed with the results of a PHQ9, they interpret a score of 10 or more as indicative of depression. As a result it is quite likely they will be placed on what they consider a suitable trajectory for a depressed client. But Zimmerman (2019) [Using the 9-item Patient Health Questionnaire to Screen for and Monitor Depression, JAMA, 322, 2125-2126] has pointed out that the instrument over diagnoses people as being in the severe depression category and misses people in the mild category. He cautions that the instrument is not diagnostic and should only be used in the context of a standardised semi-structured interview such as the SCID, measuring change. Both BABCP and the British Psychological Society have been enthusiastic backers of IAPT, but have taken no steps to ensure that PWPs are aware of the limitations of self-report measures. They bear the responsibility for the current mess – for their own reasons they have put dissemination of services ahead of everything else.

A study by Chris Williams (2018) Williams, C., McClay, C., Matthews, L., McConnachie, A., Haig, C., Walker, A., & Morrison, J. (2018). Community-based group guided self-help intervention for low mood and stress: Randomised controlled trial. The British Journal of Psychiatry, 212(2), 88-95. doi:10.1192/bjp.2017.1 shows the bizarre conclusions that can flow from reliance on the PHQ9. He and his colleagues recruited patients from the community with possible depression, with a mean PHQ9 score of 15.2 (and standard deviation of 5.4) thus over 80% (83.8%) of cases would have been regarded as depressed.  But according to the MINI diagnostic interview none of those in the immediate treatment group met criteria for depression and only 4% of those in the delayed access had depression. Despite the colossal mismatch between the PHQ9 results and the MINI  he and his colleagues concluded that ‘low intensity class based CBT delivered within a community setting is effective for reducing depression, anxiety and impaired social function’ .  This highlights the weak to non-existent evidential base for low intensity cbt.

 

Dr Mike Scott