Category: Current Psychological Therapy Issues

Issues with current psychological therapy practices, and comments on what is effective or ineffective

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Current Psychological Therapy Issues l

IAPT’s Flagship The PHQ-9 Hits An Iceberg

the PHQ-9, IAPT’s sole determinant of depression. identifies two and a half times as many people as depressed compared to the ‘gold standard’ diagnostic interview the SCID,  see Levis et al (2020) in this months issue of the Journal of Clinical Epidemiology .  This makes for garbage assessment (GA), the same measure is used by the service to measure outcome, garbage outcome (GO).  In the computer world  the mnemonic GIGO is used to denote, that if you put garbage into a computer you get garbage out. For mental health clinicians there should be a new addition to the lectionary GAGO. But who is answerable for flagship IAPT (Improving Access to Psychological Treatments) racing towards the iceberg? who is going to pick up the survivors? 

Levis et al (2020) comment that the PHQ-9 results are rather like a positive mammogram test for breast cancer, the result would give a grossly inflated view of the prevalence of breast cancer. They argue that that the PHQ-9 results only have any validity in the context of a standardised diagnostic interview. IAPT has never used such an interview, its’ claim for a 50% recovery rate is outrageous.

Interestingly the Journal paper found that there was no cut off score on the  PHQ-9 that meaningfully differentiated those in need of treatment from those who did not. Yet IAPT uses the cut off score of greater than 10 to denote a ‘case’, with an implicit treatment requirement.  Those scoring greater than 10 could be suffering from almost anything, adjustment disorder, a specific phobia, binge eating disorder etc or simply cheesed off with their debility following say the development of sepsis after an operation and ongoing impairment.

Ironically the fault with the PHQ-9 may lie in its’ origins. It was validated not against an acknowledged reference standard, such as the SCID, but against the PRIME MD, Kroenke et al (2001) J GEN INTERN MED 16:606-613 which asks in interview form exactly the same questions as on the PHQ-9. This contravenes one of the STARD, [Cohen et al (2016) doi:10.1136/bmjopen-2016- 012799 ] requirements to judge the diagnostic accuracy of a test, in that the reference standard must contain much more detailed information (e.g about levels of functional impairment) than that contained in the index test.   

The development of the PHQ-9 and the PRIME-MD were both funded by Pfizer Pharmaceuticals. The over identification of cases of depression is clearly in the interests of a pharmaceutical company. Clinicians also welcome with open arms anything that appears to reduce the assessment burden. Their employers, such as IAPT can rejoice that this surrogate  for reliable diagnosis, shows a reducing score with time [regression to the mean – Gilbody et al. (2015) looked at how GP patients with a PHQ-9 score of greater than 10 fare with usual treatment, over a four-month period; their mean PHQ-9 score reduced from 16 to 9],  which they can publicly misattribute to the benefits of therapy, and can convince the more naive of their clinicians that they are making a real world difference. IAPT continues in its’ bubble, shared with the supposed UK lead organisation for cognitive behaviour therapy, the British Association for Cognitive and Behaviour Therapy (BABCP).

Dr Mike Scott

 

 

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Current Psychological Therapy Issues IAPT l

Prestigous Journals Have Stopped Looking at Real World Mental Health Outcomes

Papers in Journals such as The Lancet, Behaviour Research and Therapy and Behavioural and Cognitive Psychotherapy have in recent years relied entirely on psychometric tests completed by clients, with no independent assessment by an outside body using a ‘gold standard’ diagnostic interview. The sole use of psychometric tests is great for academic clinicians, research papers can be produced at  pace and at little cost, securing places in academia. Conferences are dominated by their offerings but actually nothing is changing in the real world of clients.

 

 

The Lancet paper on the PACE trial on CBT  for chronic fatigue syndrome [Sharpe et al (2015) Rehabilitative treatments for chronic fatigue syndrome Lancet Psychiatry, 2, 1067-1074] provides a great example of how to ‘muddy the waters’. The authors presented CBT as making a major contribution to the treatment of CFS. But Bakanuria (2017) [ Chronic fatigue syndrome prevalence is grossly overestimated using Oxford criteria compared to Centers for Disease Control (Fukuda) criteria in a U.S population study. Fatigue: Biomedicine, Health and Behavior, ps 1-15] has pointed out that the authors used the very loose Oxford criteria for CFS, requiring mild fatigue, but the incidence of CFS is ten times less if the Center for Disease Control (CDC) rigorous criteria are used. Thus Sharpe et al had not demonstrated the efficacy of CBT in a population who truly had CFS. In December last the Lancet published a paper by Clark et al on predictors of outcome in IAPT but again the dependent variable is of  doubtful validity, changes on PHQ9 and GAD7 in a population whose  diagnostic status is unknown. In fairness in the discussion Clark et al (2017) do note that it is a limitation of their study that they have relied on self-report measures but there is no acknowledgement that their findings are actually unreliable. Doubtless their conclusion that organisational factors effect delivery of an efficacious treatment is true, but this is stating the obvious, if a treatment is found to be efficacious in a randomised controlled trial, unless there is a careful mapping of key elements in the rct e.g reliable diagnosis, ‘gold standard’ assessment, fidelity measures, there will be an inadequate translation from research into routine practice.

My hope for the New Year is objective measures of outcome so that we can truly begin serving clients, now there is a novel idea.

Dr Mike Scott

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Current Psychological Therapy Issues l

Grenfell Fire – A Cunning Plan?

Yesterday a Counsellor from the Children and Adolescents Mental Health Services (CAMHS) announced on the BBC News, that staff are going to go door to door asking whether the occupants want professional help. Is this really the best use of resources 6 months after the tragedy? The days news also contained an item on a parent averting the gaze of her children from the Grenfell Fire Tower Block as she took her children to school.

Without health staff having a clear understanding of what in effect constitutes the ‘bruising/ tissue damage’ from  the Tragedy as opposed to that which constitutes ‘disorder’ scarce resources are likely to be squandered. There is clearly a role for a preventative/ 1st Aid input, information about not blocking intrusions, the normality of a period of increased irritability, anxiety about rehousing but there also has to be a reliable assessment of dysfuntion so that an evidence based treatment can be highlighted.

Dr Mike Scott

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Current Psychological Therapy Issues IAPT

Jeremy Hunt Conned on Mental Health

Today Health Secretary, Jeremy Hunt claimed ‘ we have a world-beating service for depression and the anxiety disorders that other countries are considering adopting, particularly Sweden’ [BBC One Andrew Marr Show]  but  he appears not to know that the IAPT service he cites has never been subjected to independent scrutiny and he is victim to its’ excellent marketing.  From my own work as an Expert Witness to the Court I have found a recovery rate of just 10%, ‘IAPT the Need for Radical Reform’ (In submission) which also contains testimonies of those who have gone through the system, work on a smaller sample (n=65) is summarised in ‘Towards a Mental Health System that Works’ (2017) Routledge.

Tip of Iceberg Recover

 

I presented my findings ‘Reality Checking Psychological Services’, https://files.acrobat.com/a/preview/93ed8696-b12e-44b0-a2bd-3f0646f62052 on the smaller sample at EABCT Conference in Stockholm on  September 1st 2016. Internationally countries have not rushed to adopt the IAPT approach and are much more circumspect about the IAPT results than Mr Hunt. Unfortunately in politics the bar for ‘evidence’ is set low, with evidence outstripped by enthusiasm. On October 10th 2017 Mr Hunt announced £15 million to train 1 million people in Mental Health First Aid with 1 trained member of staff in every secondary school by 2020.  He argued plausibly on You Tube that half of emotional problems are there before age 14 and if there is some early input problems could be prevented. Nice idea, but the evidence on this is lacking, arguably the monies might be better spent on what we know does work, CBT treatment with fidelity to an evidence based protocol.  Whether or not,  he anticipated the training would be online with volunteers who could thereby become less stressed, more ‘resilient’ and help others!

 

Dr Mike Scott

 

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Current Psychological Therapy Issues IAPT

CBT for Addictions – As Likely As Winning At Roulette

There has been an outbreak of smashing fruit machines in Liverpool: this week a man was given a 12 month suspended sentence for wrecking a well known Bookmakers machines, he protested that they were not helping him overcome his addiction! This followed hot on the heels of the brilliant fictional TV series ‘Broken’ (filmed in Liverpool) which showed identical behaviour in the wake of the suicide of a gambling addict.

A person I saw recently Mr X ,with a lifelong gambling addiction told me that the longest period he had been without gambling was when he bet a fellow gambler who would last longest, he lasted 2 weeks. Sadly his experience of IAPT was woeful he was introduced to the discredited stop technique to distract himself when he had the urge to gamble.  He said that he had a few sessions with the therapist but the therapist left and he was given a new therapist.  Mr X said that a questionnaire was then administered and because he got below certain thresholds it was deemed that he did not need counselling and the therapy was terminated.  He said that he was alarmed at this because he felt suicidal and he wrote a letter of complaint and was then offered further sessions but declined them because he had lost trust in the enterprise.

Addiction services have been managed by local authorities since 2012 , but with typical cuts of 30% many services struggle. People can fall between services as a tender is often times switched after 3 years.

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Current Psychological Therapy Issues IAPT

CBT for Severe Mental Illness – Does It Reach the Parts That Matter?

Is IAPT overeaching itself by straying into the Severe Mental Illness arena? ‘Ian’ had a life long history of psychosis, he had a great deal of support/treatment over the years from Richard Bentall, author of the brilliant book ‘Madness Explained’, for which the family were most appreciative.  Unfortunately Ian had his benefit withdrawn on the grounds that he was ‘fit for work’ and I was asked to help. Within  two minutes of my seeing  Ian it was abundantly obvious to anyone that he could not work, he was so agitated,  his visits to coffee shops often curtailed by his paranoia.  In the event I produced a report, which alongside a letter from Richard resulted in his benefit being reinstated, his parents were delighted. I did offer Ian the opportunity to look at better ways of handling his paranoia etc but he declined.  I felt desperately sorry for him and reflected that even if he had taken up my offer I doubt that I would have made a real world difference, at best he would have been thankful for my efforts. I wonder whether CBT for psychosis has been oversold.

In using the term ‘severe mental  illness’ I toyed between this term and psychosis, I was trying to use a common language with the reader and in writing my report to the DWP I said that Ian met the DSM diagnostic criteria for schiziophrenia. Labels can be problematic and indeed might not have a biological basis but they give a direction for treatment and influence eligibility for benefits. Richard Bentall et al wrote an Expert review ‘Drop the language of disorder’ in Evidence Based Mental Health, February 2013 and recommended a ‘problem definition, formulation’ approach rather than a ‘diagnosis treatment’ approach, but in my view it is not a matter of ‘either or’ but a matter of both.  Notwithstanding our differences neither of us were able to make a real world difference in what I would see for want of a better term is Ian’s schizophrenia.

IAPT has a demonstration site for Severe Mental Illness for people with psychosis, bipolar disorder and personality disorder, before disseminating such a service there needs to be independent verification using clinician-rated measures (PSYRATS for hallucinations and delusions, SCID for personality disorders) that such a such service would add anything over and above support in the community, otherwise it is just extending an empire.

Dr Mike Scott

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Current Psychological Therapy Issues

Casualties of Foolhardiness

The more I listen to, read about and consider the progress (or lack of it) of the project that is called Improving Access to Psychological Therapies (IAPT) the more thoughts of the actions of the generals in World War One spring to mind. Haig was a classic study in the unwavering belief of cavalry even in the face of machine guns, he had no idea of the conditions his troops were fighting in, he believed that numbers would win out, just like MacNamara fifty years later in Vietnam.Both believed in numbers, sheer volume would win the war for them.

Image result for mental health casualties

Clark, and his side kick Lord Layard, like his ignominious predecessors, consider that sheer volume of numbers will be sufficient to defeat the epidemic that is mental illness. While Clark and Layard’s numbers are statistics, people are still dying as a result, those sent to fight the war are still being burned out by sheer effort of trying to help others in impossible conditions. For example, 50% of professionals working in front line mental health services are suffering psychological distress, the conditions are intolerable yet most are too frightened to say so. The pressure to achieve a “50% success rate” means that statistics are skewed or even changed to achieved the necessary figure. Professionals are sent for retraining if they don’t achieve and then sent back into the frontline. In the First World War, many soldiers had their wounds stitched up and were then sent back into the front line. As I type this it reminds me of the horses ridden by the toreadors in bull fights; if the horses were gored by the bull they were taken out of the ring stitched up and sent back into ring immediately – amazing cruelty. The same is happening to frontline staff in IAPT.

Yet the politicians are being fed an amazing story of success, in exactly the same way that Haig and others in the First World War sent back messages that told the politicians how well they were doing.

This quote from Historynet really sums it up:
“Haig waged the ensuing political battle with customary remorselessness and prevailed in the bureaucratic trenches. He got everything he wanted in the way of men and materiel for what became known as Third Ypres or Passchendaele, a battle remembered for, among other things, terrain so wet the entire world seemed to consist of nothing but mud and shell holes filled with vile water. Indeed, in no land battle in history did so many men die by drowning.”

Image result for casualties of mental health

So many people are drowning as a result of the disaster that is the Project called Improving Access to Psychological Therapies, clients and professionals alike; yet the politicians remain enamoured of the project’s ability to blame the individual for their failure. It matters not whether it be client or professional, the failure lies within the individual, this is the overbearing ideology of the current government and those who seek to prove the model that is supposed to be Improving Access to Psychological Therapies.

Like Haig, Clark seeks to prove his model by asking for more troops (which, like Haig, will be refused; the worst of all worlds) rather than look at the overwhelming evidence that it is not working. For example, of all those who are referred to the service only 16% make some kind of recovery based upon the analysis of psychometric tools. From a service point of view this is a disaster. No company would continue to function on that basis. Yet the government continues to prop up the project on the basis that it is making a difference. What makes it worse is that IAPT continues to mark its own homework – it is time for an independent review.

There has been no measurable difference to the well being of the country as a whole, and only a few lucky people have benefitted as individuals. With regard to the overall well being of the country we are slipping behind that of other nations and if austerity continues the environment will only continue to get worse. As I have said so many times before, a toxic environment cannot be combatted by providing a leaky gas mask. Therapy and resilience training are no match for a cruel and heartless environment created by cruel and heartless politicians.

References:
http://www.historynet.com/field-marshal-sir-douglas-haig-world-war-is-worst-general.htm

Steve Flatt

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Current Psychological Therapy Issues

Mental Health Sinkhole Appears – Untold Casualties

 

 

Mental Health Trusts today announced that three quarters of extra monies promised for mental health services are not getting through. A mental health sinkhole has appeared, the depth of which is measured by under-funding and the width by poor quality services. Casualties include an estimated 694,000 people who were treatment failures in the Government funded IAPT service in 2014/2015, 85% of those treated. A further one third of those referred to IAPT did not enter treatment.

I reviewed the trajectories of 65 people who went through IAPT Services in the North West of England using a ‘gold standard’ diagnostic interview just 15% recovered from their disorder. [ Scott (2017) Towards a Mental Health System that Works London: Routledge].  I am wholly independent of IAPT and I made the analysis on the basis of data available to me as an Expert Witness to the Court. Applying this recovery rate to the national picture suggests a massive casualty rate.

Just this past week I picked up a ‘casualty’ who had had 6 sessions with IAPT, she had had a fall 2 years ago, become effectively housebound, though able to walk for 10-15 mins. She was referred to IAPT and had 6 sessions of CBT for depression, to no avail and she was very frustrated by the therapist who had said ‘do you think you might have OCD?’ one week then the next week ‘what about body dysmorphic disorder?’.  No further treatment was offered. I  found she was depressed  but what had not been identified or addressed was that she had a phobia about falling and sustaining further injury. It was this phobia that was driving the depression and needed to be the therapeutic focus.

Dr Mike Scott

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Current Psychological Therapy Issues

Evidence Based CBT Joins the ‘Endangered Species’ List

‘The good news is we have successfully amputated your right leg, the bad news is we operated on the wrong leg’.  The moral is that there can be no evidence based CBT treatment without an evidence based assessment (EBA). But EBA’s are increasingly absent in order to ease the research burden, ‘just rely on a psychometric test’, and reduce ‘treatment’ costs.

Emergency medicine operates on the 7 P’s, ‘Proper Pre-planning Prevents Piss-Poor Performance’. Is it seriously proper-pre-planning to operate as IAPT do, with a  typically 15-20 minute telephone conversation, conducted by the most junior member of staff, to be then placed on waiting list of upto 6 months for a treatment of indeterminate appropriateness? The reliability of this ‘pre-planning’ has never been assessed by anyone independent of IAPT. But this has not stopped Clinical Commissioning Groups often ring fencing IAPT monies at the expense of other mental health service providers.   The CCG’s need to be reminded that they ought to be working in an evidence based framework were the results of randomised controlled trials with independent assessment of outcomes hold sway (the top of the pyramid below). 60% of IAPT clients receive low intensity treatment, this is way down at the bottom of the evidence pyramid below, with a high potential for bias, reflected in powerful marketing.

It is time that CCG’s told IAPT that their pre-planning is simply unacceptable, there has to be an evidence based assessment. It is time the National Audit Office asked why are we continuing to fund a Service that has not been independently evaluated using ‘gold standard’, diagnostic assessment procedure. But most of all it is time to listen to those subjected to an inhospitable and unhelpful service. MP’s have to insist they are listened to.

Dr Mike Scott

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Current Psychological Therapy Issues

Saving Normal, Candidates for CBT and Sean Bean

 

Tonight I am planning to watch another episode of the TV drama  ‘Broken’ starring Sean Bean as the central character. He plays Fr Michael who was sexually abused as a child by a priest and had a destructive late adolescence/early adulthood. Fr Michael has uncued flashbacks of the abuse, at times like consecrating the Eucharist. In the last episode he angrily confronted his abuser. But since becoming a priest Fr Michael has nobly served the severely disadvantaged. It was filmed at St Vincent’s, Church, Liverpool directly opposite where I work.  Should I nip across and offer EMDR /CBT?

Set for ‘Broken’

This fictional example echoes a real life conundrum for clinicians – a colleague of mine recently brought to my attention the case of a lady who had intrusive flashbacks of the aftermath of ECT and wondered whether she needed EMDR. By coincidence I had assessed the lady and knew that she was suffering neither from depression or PTSD and had functioned well for many years. She came to my colleagues attention because of some inherently stressful life events. My response was in the words of Allen Frances’ seminal work ‘Saving Normal’ published in 2013 by William Morrow we must not pathologise every uncomfortable memory, the acid test is whether it is directly causing significant functional impairment now.

In a similar vein I remember seeing a lady some time ago who had undergone prolonged sexual abuse as a child, she had been referred to a number of therapists over the years and they had all wanted to focus on the abuse. She protested that the abuse did not get in the way she was simply anxious about everything. When I saw her I found she was just suffering from generalised anxiety disorder, nothing more nothing less. I treated her with a standard protocol for GAD and she recovered.

I think the answer to all of this is “If it is not ‘Broken’ don’t fix it”, I’m off to watch the TV.

Dr Mike Scott