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

A Country called IAPT

Imagine you lived in a country where there was a pharmacy and a GP in every town but few hospitals. The pharmacy and GP’s services were widely advertised, encouraging all the unwell, or those who had not really thought of their symptoms before as illnesses to come in, get checked out and get treatment. The government set targets that a certain percentage of the population must be treated by the pharmacy and GP each year – if that target was not met the commissioners would be castigated by NHS England and an expensive tender process would be instigated, to bring “healthy competition“ to the market.

What if a GP and pharmacy were successful in advertising for all the patients and people turned up in their hundreds per month? You realise that you have not got enough supplies and enough staff to treat them all, so you “innovate” new methods, such as getting 12 patients at a time into the room and talking to them about what might be wrong rather than having time to check their individual symptoms. People with symptoms of diabetes were taught about diabetes, if the symptoms were there for another reason and didn’t resolve– what then? Maybe send them on another course and see if that sorted them out, maybe some internet self-help on diet or lifestyle would do – or, maybe they need to be checked out at hospital…..oh….there is no hospital, there was no money to concurrently expand the hospital, in fact, commissioners had saved money on the quiet by closing the hospital because there are no government targets for treating those outside of the GP and pharmacy. There are just a few hospitals further away with not enough capacity to see any more people whose piles may actually be bowel cancer or whose aches and pains are actually a degenerative rheumatoid arthritis.

As a patient who needed more than the GP and pharmacy can offer, you are confused and sad and angry -the GP and pharmacy advertised all over town saying – come and see us if you have these symptoms, but then you are told that there is nowhere to go if physio doesn’t fix that carpal tunnel and you need an operation, nowhere to go for the intravenous antibiotics for your severe infection where the standard course is not enough.

Imagine being a staff member at the pharmacy or GP – wanting to care for people and help them but having no time, having to break the bad news that, yes, there are recognised treatments for what you have but only at hospitals and we don’t have one of them, there is a private one but if you can’t pay you will go unwell and untreated. Might it seem to you that you need more staff to at least try and better help with the supplies that you do have? Oh, you discover that, although the government set guidelines for numbers to be seen, wait list times and recovery rates they set no guidelines for staff numbers and experience. So the commissioners have no basis to give you more budget for more staff and tell you rather to get on with the job or you will lose the service to another provider who magically can get the job done. Might you become stressed, depressed and less able to do your job?

This country is IAPT country. The country that demanded that its services for mild to moderate mental health conditions be built, with high targets to meet, with no proper staffing guidelines. The country that forgot to consider that expanding a mild to moderate service would attract the full spectrum of mental ill health. The country that once did the maths for how many therapists would be needed on the back of an envelope and then lost the envelope.

The country that forgot that not expanding but actually cutting your services for the more unwell would breed the cruelty of unattainable promises to the unwell, staff exhaustion and a desperation that leads to cooking the books to show that targets are met rather than standing up and saying that the Emperor of this country who proclaims that IAPT data is sound and targets are met has no clothes on.

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’, 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


IAPT Behind Closed Doors – Compulsion and Inadequate Training

There is certainly a high degree of compulsion associated with attending IAPT services, with people being told that if they do not attend IAPT interventions then their benefits may be stopped.  This seems counter to the idea of patients’ voluntary engagement, with the notion of ‘opt in’ being the sole indicator of patient willingness for participation.  My personal opinion is that there is no real choice and no other type of treatment offered if they refuse.  IAPT is a service where clear up target rates appear to be more important than the quality of the treatment and ‘one size’ most certainly does not fit all.

I am of the opinion that my colleagues who are Psychological Wellbeing Practitioners would benefit greatly from having knowledge and experience of mental health since my experience was that most of the higher level CBT Practitioners were and are mental health nurses by discipline.  Whilst I am critical of IAPT, I am also critical of mental health services and for this reason I am currently aiming to change direction and to re-train in the area of Psychology.

Anonymity protected Dr Mike Scott

‘What Proportion of People With This, Recover With This Treatment?’

If you are undergoing a medical procedure this is a pressing question. Curiously, psychological therapists create an aura in which clients are disuaded from asking this question, with responses that amount to ‘we don’t like to use labels, just complete questionnaires to see how you go’, masking a wholesale distrust of the medical model.  Clients are intimidated from voicing their basic concerns, when asked whether they were given a diagnosis usually the response is ‘no’ or  “they said I had ‘x’ symptoms” either way they do not feel on solid ground. Invalidating a person/client’s nascent question whether it be the ‘meaning of life’ or the likelihood of treatment that makes a socially significant difference is direspectful.

IAPT obscures the answering of this question by a sleight of hand, using changes on 2 psychometric tests to indicate recovery, with no blind, independent assessment of outcome and no use of a ‘gold standard’ diagnostic interview. But this obscurantism is not confined to Government funded psychological therapy services, in private practice there is an equal failure of diagnostic accuracy and comprehensive evaluation at both initial assessment and at the end of treatment. However at least in the private sector one can search out a therapist who can deliver, no such option is available within IAPT.


Dr Mike Scott

IAPT Behind Closed Doors – The Need for Listening and Flexibility

At Bury I had occasion to treat an older gentleman who lived alone and had no family locally.  He also had received step 3 CBT work on at least 2 occasions previously and he had been re  – referred to me at step 2.  This gentleman had a stammer and a thick Scottish accent and did not speak often, as he was anxious and low in mood since he was embarrassed that people did not understand him.  My brief was to “get him out and mixing with other people”.  I discovered that he did not go out very often and had been interested in computers in the past, going on a Government scheme to learn more, until the funding was stopped.  He showed me his phone, which was his “lifeline” and stated that he had got it a few years ago, but that it was quite expensive to run.  He told me about his female companion, who was unfortunately ill and who used to accompany him to the Library when she had been well, as he did not cope well in public.  I began thinking about his phone and his love of computers


Over the first 3 sessions, I understood that he was not a particularly social person, could not afford a computer of his own, but was able to consider that he may get a better phone and a better deal than the one he had.  I did not see this gentleman for 2 weeks, as he sent word that he had a cold, but by the 4th session, he had been on his own to a local branch of Carphone Warehouse and had negotiated a deal on a new phone which had a full screen internet access and which was affordable.  He recovered to the extent that not only was he able to go out alone to places now, he was going to coffee shops and public places accessing the free internet there to talk to his many friends over the internet and was no longer a person who avoided people, because he could now make himself understood.  I remember his words to me at session 5 when I discharged him, telling me, “the world is mine!” and about how his female friend was also recovering with his help.  He explained that she had always had to help him to go shopping and to explain things for him, but that now he had more confidence, he was doing things for her for a change.  The key for him was being understood and improving his life through his talents and his love of computers and gadgetry.  Everything else followed on from this.

One of my better experiences at Bury was with a lady who was referred onto my caseload because she had long – standing issues with physical injury sustained at work and who was in the process of claiming compensation from her employer for her injury.  She was newly married and had become extremely anxious and suffered with co-morbid depression.  She had been seen and treated with CBT at step 3 twice before and was also referred to Mindfulness Relaxation.  She was referred to me at step 2 because she had “failed to be able to use mindfulness to relax and was still anxious and suffering from depression”.  I had 6 sessions with this lady and she missed one because of needing to go to court to represent herself for her case, but this was tagged on the end for review.  I adapted an approach for this lady’s needs which did not include mindfulness and helped her to see her new situation not so much in terms of what she could no longer do, but with an emphasis on new opportunities.

This demonstrated that current IAPT approaches are markedly inflexible and there is little or no notion of adaptation to suit individual needs and also, too much emphasis on “getting the list down”.


Anonymity protected Dr Mike Scott

‘We’ll Spin the IAPT Wheel To See What You Need’

Maybe the IAPT wheel will stop at counselling, or perhaps low intensity CBT or maybe  high intensity CBT! I have just  had a client who was within 6 weeks of a road traffic accident given an IAPT telephone assessment and deemed in need of low intensity CBT, but didn’t attend the scheduled treatment appointment and therefore discharged. 14 weeks post rta  he underwent a further telephone assessment and was now deemed in need of high intensity CBT, unsurprisingly he DNA’d the first treatment appointment.      The GP was provided with no explanation of the rationale followed by IAPT nor was he furnished with any psychometric test data. Accountability?

It is difficult to see the logic of IAPT’s position, other than to be seen to offer a speedy service,  it could be argued that some distress post rta is normal and in the interests of ‘saving normal’ (and resources) waiting and seeing a little longer would have been helpful . Perhaps a case for counselling could be made but on what basis?


Dr Mike Scott

IAPT Behind Closed Doors – Falsifying Quality Control Data

My experience is that at least one person was found to have massaged the figures to reflect a greater recovery rate and consequent discharge.  This was only discovered following a particularly high level of re-referrals for ex-patients and subsequent complaints.

With regard to the PHQ 9 and GAD 7 scoring system, I feel that this could be open to abuse.  This may be because workers are under great pressure to perform and elicit results.  I believe this to have taken place as a consequence of almost overwhelming pressure to discharge referrals.  With more discharges came more referrals and there was never any acknowledgement of best practice or learning lessons appropriately.  I understood also that PHQ 9 and GAD 7 only had pertinence for those suffering from mild to moderate mental health conditions.  I had to use other tests for those persons who had suffered past trauma and more severe mental illness which I myself as a practitioner “filtered out” as a consequence of them being incorrectly referred to step 2 services.

Anonymity protected – Dr Mike Scott

Telephone First Consultations Fail

IAPT is synonymous with telephone first consultations, but the first independent study of this intended cost saving device, with GP’s, has shown it fails to deliver. An editorial in this week’s British Medical Journal on the Newbould et al study* (2017) states:

‘ Telephone first systems alone will not solve the perennial problem of ensuring timely, safe, and equitable access….It is also yet another reminder of the importance of independent evaluation of initiatives before investment in widespread implementation’

Instead of piloting and having an independent evaluation, IAPT has ploughed on regardless. Accountability is a major issue for IAPT, it positions itself between primary  and secondary care but is accountable to neither. It claims comprehensive data collection on almost all its clients. Yet in the authors examination of 90 cases (In preparation) that went through IAPT, for clients having two or more treatment sessions, before and end of treatment psychometric test data was given to GPs in less than half of cases. One quarter of cases did not clear the first hurdle of either ringing IAPT for a telephone assessment or IAPT being unable to contact the person. Whilst 13.3% ‘attended’ only the initial assessment. Thus IAPT is failing to engage just less than 4 out of 10 clients.


In GP practices with telephone first consultation the proportion of patients who would recommend their practice to friends fell. There was also a reported increase in emergency admissions associated with telephone first systems.

Clinical Commissioning Groups should insist on IAPT reforming itself, by dropping telephone first consultations.

* Newbould et al (2017 Evaluation of telephone first approach to demand management in English general practice: observational study. BMJ: 358:j4187

Dr Mike Scott

IAPT Behind Closed Doors – Like Jumping Into a Cold Plunge!

Throughout my time in IAPT in Lancashire (I had 2 separate occasions working there) I was employed as a PWP and was taken on to “get the waiting list down” in terms of the volume of cases which had been referred, predominantly by GPs.  I am an Agency Nurse who has worked in many roles across the country, but this was my first role as a PWP.  The first thing that occurred to me was how little awareness the PWPs had about mental health and how people were allocated to various parts of the Service.  There seemed to be an emphasis on “clearing the lists” because lengthy lists would not be favourably looked upon by the commissioners and may affect the funding already provided for the Service, but also future funding.

My PWP colleagues were very new in practice and many of them had only recently qualified and as I have previously outlined, they had little or no experience around mental health.  I was initially asked to “look after them”, since it was very common when working over the telephone to find a suicidal patient on the other end and have a colleague not know what to do.  I was often asked to sit in the room with my colleague and to support through the assessment, as I was in a position to know when to call an ambulance or to get further assistance, where often they did not.  Many patients who were referred to IAPT services, especially at step 2, were referred wholly inappropriately.  My colleagues were subjected to a degree of unnecessary distress and pressure by these inappropriate referrals, as they knew that they were inappropriate, but were expected to treat them in any case.  In cases of face to face referrals, the situation was often worse, since inexperienced colleagues very often were asked to give 6 or 8 sessions to someone who had been referred who was actively psychotic, but whom the PWP did not recognise as being psychotic.  The result of this at best, was that the patient never got better and at worst, may have harmed either themselves or another person.  There were also safety issues in terms of lone working in buildings which were vacated at 5 pm but in which it was expected that workers would have to receive patients because the Service was open until 7 pm.

Anonymity protected – Dr Mike Scott