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Implementing and Monitoring Adherence to NICE Guidelines for Depression and the Anxiety Disorders

The evidence on the translation of the Guidelines  to routine practice is conspicuous by its’ absence. Claims to be NICE compliant are used by mental health service providers to secure funding, but without credible evidence of the Guidelines influencing routine practice. But some individual practitioners within providers such as NHS Talking therapies and Anxiety UK may be compliant. As may some independent practitioners.

There is no agreed audit tool, despite spending £2 billion a year on NHS Talking Therapies

NICE guidelines are diagnosis specific, but NHS Talking Therapies’ practitioners do not make diagnoses, making compliance impossible.  Instead its’ clinicians assign an ICD-10 diagnostic code, to what they see as the main presenting problem.  But there is no evidence that this is a reliable surrogate for a standardised diagnostic interview. The randomised controlled trials on which the Guidelines are based, begin with a reliable diagnosis and a matching treatment protocol.  In NHS Talking Therapies there is ‘no key and lock’.

Rather treatments are random, with alleged CBT programmes for disorders such as ‘mixed anxiety and depressive disorder’, that are not in the NICE lexicon. Yet, we are invited to believe that the recovery rate for this, protocol-free disorder, of over 50%,   is on a par with the general recovery rate! 

In my book Simply Effective Cognitive Behaviour Therapy (2009) London: Routledge, using the idea of a Sat Nav, I identified the treatment targets for each disorder and the matching treatment protocol. Making it possible for clinicians to get to their destination.  But in years since the inception of IAPT, out of the 100’s of treatment records I have reviewed, there has been scarce evidence of compliance to any treatment protocol (fidelity) and in the rare instances where it has occurred, there has been no flexibility e.g  persistence with a trauma focussed approach, which was clearly not working, leading the client to default. Flexibility within fidelity has not materialised.

Dr Mike Scott

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NHS Talking Therapies ‘Thanks, But No Thanks’

One in three of those who attend NHS Talking Therapies sessions do so for only one session, this led to the title of my just published paper Scott (2024). Following a Freedom of Information (FOI) request, I obtained data on those attending just one assessment/treatment session. The Service has chosen to focus on those who attend two or more sessions and its’ recovery claims refer to this population. But this is an incomplete picture as there has been a ‘haemorrhaging’ before treatment.

The mean number of treatment sessions attended is 7-8, but this means that half of those treated have less than 7-8 sessions. But NICE recommended treatments for depression and the anxiety disorders are typically for 12+ sessions. Thus at least half those treated by NHS Talking Therapies have a sub-therapeutic dose of treatment. This makes the Services claim for comparable effectiveness (50% recovery) to randomised controlled trials, where there is no ‘haemorrhaging’, preposterous, pure marketing.

 The paper also reveals that the Service has a claimed recovery rate for ‘mixed anxiety and depressive disorder’, that is comparable to other disorders. But there is no NICE recommended protocol for this disorder, it is therefore impossible for it to be NICE compliant. This suggests NHS Talking Therapies get the same ‘result’ however they label a disorder and whatever intervention they deliver. In Scott (2024) I suggest that the Service has capitalised on a placebo effect – the results reflect, simply a combination of: attention, raised expectations, improvement with time and the clients desire to please their therapist. Further the within subject effect sizes are identical  to those found in the placebo arms of the most reliable rcts. My paper reveals that those with ‘mixed anxiety and depressive disorder’ and PTSD are the least likely to engage in treatment. With regards to the first it is likely because no credible rationale for the disorder can be given. For PTSD it is likely because of therapeutic insistence that trauma focussed treatment is the only way forward, when in fact there is a much more user friendly option Scott (2022).

Dr Mike Scott

Erratum: The publishers of the paper Wiley and Sons, missed out including the bottom 3 rows of Table One, they are:

8.  2929  11.9    14.3  9316    11.4  0.9  3.2

Hyp
9.
    2030   16.1   14.9  4487    15   0.8   2.2

Ag

10.
   1560   10.3   11.5    4717     11.5 0.8   3.0

Spec

 

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NHS Talking Therapies Proceeds by Copying

but as anyone knows who has copied a fellow pupil’s homework, this can end in tears! The Service believes, it disseminates ‘best practice’ by networking clinicians together. But there is no evidence that this is the case.Those most vocal or most eminent are likely to hold sway. Ensuring the dominance of eminence not evidence-based treatment. This runs the risk of creating a totalitarian culture in which it is not possible to express a dissenting opinion. The power-holders then control what is published in journals/publications. But like the Russian regime of the 1980’s they would vigorously protest that they are engaged in Glasnost (0penness).

The use of artificial intelligence in mental health is an exemplar, ‘par  excellence’ of copying. The authors of IESO claim that its interactive text messaging service for clients, is based on the careful selection and analysis of client-therapist exchanges and that they have determined what works. If indeed this were the case it would make the provision of mental heath services much cheaper for the NHS (as well as making a nice profit for IESO). But no such reliable database with real-world outcomes e.g being free of a disorder as assessed by an independent observer for at least 8 weeks, has been determined.There are no published papers to substantiate a real-world effect. Without fidelity checks there can be no assurance of the translation of an evidence-based treatment to routine practice.

I recently read James Davies’s book Sedated: How Capitalism Has Created the Mental Health Crisis, (2021) Atlantic Books, without necessarily buying into his thesis that Capitalism is the arch-enemy, it is certainly the case that financial factors ( NHS Talking Therapies cost the taxpayer £ 2 billion a year), coupled with the opportunity to exercise unbridled power has produced a dysfunctional mental health system. But the problems are not confined to primary care, I recently saw a client who has had 4 years of secondary care treatment in relation to child abuse, the records revealed no objective audit. This echoes the National Audit Offices failure to provide any credible independent assessment of mental health services. There is an inherent believe that the mental health services must be all too the good because the clinicians are well-intentioned. But if they had stopped long enough to listen to my client he would have told them ‘I need a new approach, I have plateaued’. In reality there is no Glasnost. Let’s no be copy-cats.

 

Dr Mike Scott

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NHS Talking Therapies Digital Courtship

 

 

Tomorrow the Service is hosting a 3-hour webinar funded by two artificial intelligence agencies IESO and Limbic. This comes hot on the heels of the Irish Advertising Standards Agency finding SilverCloud guilty of breaching advertising standards in citing its’ recovery rate. In fairness I could see no such extravagant claims from IESO.  Nevertheless, IESO claims its:

 

 

‘app-based programme is comprised of a unique blend of evidence-based CBT approaches. They have been carefully selected having been shown, through analysis of ieso’s dataset of 750,000 hours of delivered therapy, to be the most effective with patients’.

 

But there is no published evidence that this ‘unique blend is effective’. Nor is there any evidence that the 750,000 hours of delivered therapy were assessed independently with fidelity checks to ensure that the alleged treatments actually took place.   

 

There is a computer adage GIGO – ‘garbage in, garbage out’ . There is no assurance  that the programme does not constitute ‘garbage in’.  But the programme is it seems user-friendly with a conversational style aping programmes for building your own website.  Unsurprisingly it has therefore gained traction:

‘Through our award-winning digital platform, ieso has delivered therapeutic interventions to 135,000+ people with over 750,000 hours of treatment provided. We use a typed modality which captures, with permission, the exchange between a therapist and patient all in an ISO27001-compliant manner’. 

There is an aura of misleading scientific respectability, is this yet a further breach of advertising standards?  AI may have a potential impact, but this offering is for the forseeable future likely to frustrate the consumer, who at a minimum will find it too            time-consuming.

 

Dr Mike Scott

 

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NHS Talking Therapies’ Partner SilverCloud Found Guilty of Breaching Advertising Standards

 

The Irish Advertising Standard Authority, concluded  on  October 3rd 2024, that SilverClouds advertisement of a recovery rate “up to 65%” should not be published again.  In their judgement the IASA said  that no evidence had been provided to substantiate the recovery rate and expressed concern at the advertiser’s failure to respond.  Yet SilverCloud claims to support “80% of NHS Services”. Both NHS Talking Therapies and SilverCloud have refused to engage in any public debate. Despite attracting Government funding of £2billion a year, there has been no publicly funded independent evaluation of effectiveness. 

 The best independent evidence Scott (2018), suggests that only the tip of the iceberg recover.  Unfortunately NHS Talking Therapies, are it seems answerable to no one and there is no indication that they are abandoning their absurd claim of a 50% recovery rate.

The claim that 65% achieve clinically significant improvement, has a scientific aura about it for a member of the public, but with no idea as to what it means in real world terms. They might consider that as ‘77% of volunteers agreed that volunteering improved their mental health and wellbeing’, National Council for Voluntary Organisations survey 2019, this was actually a better investment.  The implication of SilverCloud’s claim is that it is the use of their product that has brought about the ‘significant improvement’ but this has not been demonstrated. The said improvement could represent regression to the mean, patients presenting at their worst and becoming a bit better with time. Equally it could represent the client’s wish to please the therapist and/or to feel that they have not wasted their time. The claim of ‘significant improvement’ because of usage of the product is not evidence-based and is simply a marketing ploy.

NHS Talking Therapies have produced no evidence that its’ therapists using SilverCloud make any added difference to their clients over and above that of those who didn’t use it. But the juggernaut roles on, with SilverCloud advocated by NHS Scotland for those with long-term conditions!

Dr Mike Scott

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NHS Talking Therapies – No Better Than Placebo

NHS Talking Therapies boasts a 50% recovery rate. This doesn’t square, easily with the Prime Minister’s view that the NHS is ‘broken’.

A letter from Lord Darzi to the Secretary of State for Health and Social Care, dated 25 September 2024 states 

 ‘The first step to rebuilding public trust and confidence in the NHS is to be completely honest about where it stands’. But nobody is telling the truth, that NHS Talking Therapies is performing no better than placebo. Lord Darzi in paragraph 18 of his report      re-iterates NHS Talking Therapies claim of 50% recovery, with approval and without any quibble.

Marketing its’ mantra of a 50% recovery, NHS Talking Therapy has secured Government funding of £2billion a year. [Effect Size (ES) is a measure of change with an intervention]. But the published NHS Talking Therapies results show that the Effect Sizes ( i.e the difference between the post and pre-treatment scores divided by the pooled standard deviation) are no different to a placebo response. The placebo response takes account that disorders take an episodic course (i.e that symptoms naturally vary over time), and that people respond to attention, compassionate care and regression to the mean (improvement over time, first attending at their worst). Further it makes no difference whether the Service delivers alleged CBT or anything else, casting doubt on the meaningfulness of its training regime.

In the table below the Effect Size in NHS Talking Therapies for CBT (Table 4n, Annual Report 2022=2023) is contrasted with the Effect Size for placebos from the Bschor et al (2024) study.

[Extract from  Bschor et al (2024) Figure 1. Random-Effects Meta-Analysis Estimates of Pooled Pre-Post Placebo Effect Sizes ]

Diagnosis

Effect Size (Placebo)

Bschor et al (2024

CBT Effect Sizes NHS Talking Therapies PHQ9 (GAD7)

MDD

1.40

1.0 (0.8)

GAD

1.23

0.8 (1.2)

Panic disorder

0.92

0.7 (1.0)

PTSD

0.84

0.8 (0.9)

Social phobia

0.72

0.8 (1.0)

 

NHS Talking Therapies uses a category of ‘Anxiety’ for the biggest grouping of those receiving CBT with an ES of 0.7 on the PHQ-9, and 1.0 on the GAD-7. They thus do no better than placebo. The Service also uses a category ‘Mixed Anxiety and Depressive Disorder’ , with respective Effect Sizes of 1 (PHQ-9) and 1.1 (GAD-7), again no better than placebo.  But ‘Anxiety’ and Mixed Anxiety and Depressive Disorder are not categories used in the Bschor et al (2024)study or in DSM-5-TR. Not only does NHS Talking Therapies CBT appear ineffective but the Service uses its’ own nomenclature, making comparison’s difficult.

NHS Talking Therapies, for anxiety and depression, Annual reports, 2022-23

However, NHS Talking Therapies Categorises Its’ Treatments, There Is No Discernible Effect On Outcome

The results are no different if just those at caseness (PHQ-9 score  10 or more) are considered, see table below:

   

No 0f cases

633236

Start        

sd

End

sd

ES

Dep

  

268743

17

4.7

10.2

6.5

1.5

GAD

  

174049

13.4

5.5

8.1

5.9

1

PTSD

  

35234

17

5.5

11.3

7.2

1

Mixed

  

16677

16.1

5.1

10.1

6.5

1.2

Socl

  

18320

13.9

5.7

8.7

6.2

0.9

Panic

  

14759

13.8

6

8.5

6.5

0.9

OCD

  

16105

13.4

6

8.5

6.3

0.8

Hyp

  

9316

11.4

6.1

6.2

5.7

0.9

Agor

  

4487

15

6.1

10.4

7.1

0.8

Specific

  

4717

11.5

5.8

6.7

5.7

0.8

 

Thus, it appears to make no difference to whether NHS Talking Therapies delivers alleged CBT, or whatever it delivers. Casting doubt on the meaningfulness of its’ training regime.
 
   

Table 4n Cognitive behaviour therapy (CBT) outcome scores means, standard deviations, effect sizes and outcome measures by diagnosis and organisation, 2022-23

NHS Talking Therapies, for anxiety and depression, Annual reports, 2022-23

 

Dr Mike Scott

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NHS Talking Therapies – Where Therapeutic Outcome is Designed for Income

Clients attend psychological therapy with a perceived problem/s to be solved. The resolution of the problem/s has therefore to be an integral part of outcome. Is a psychometric test score result, a reasonable surrogate for a resolution of a problem/s? NHS Talking Therapies claims it is. The received mantra is that 50% of the Service’s clients score below the cut-off for a ‘case’ at their last contact with the Service, an alleged 50% recovery rate. 

By the Services own metric, it has a very marketable product, attracting Government funding of £2 billion a year for adult and child services. There is no wish on the part of politicians,  Healthcare professionals or the media to scrutinise the Service’s claim, they understandably want to believe that they are making a difference. But it behoves all concerned to consider alternative explanations for the apparent ‘success’, however this does require effort and it is easy for the professionals to claim competing demands on their time. It is comforting to think that 1 in 2 of those attending for psychological treatment are permanently recovered. But there is no evidence of the permanence of any positive change as clients traverse NHS Talking Therapies. Fluctuations in the severity of any disorder is the norm, seizing on a ‘flash in the pan, dip’ is at best, disingenuous and at worst *******.  

Dr Mike Scott

 

 

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If You Contact NHS Talking Therapies Can You Tell If You Are Interacting With A Human Being?

A just published paper in The International Journal of Social Psychiatry, by Arundell et al (2024) reports the experience of 12 clients:

  1. A long wait was often the first thing participants reported when asked about challenges with accessing NHSTT treatment:

. . .there was a huge delay from the time the referral was done back in May till I got my first session in November. . .So the GP referred, and I didn’t hear back until November. [P.12]

Another challenge was the limited support offered whilst waiting to begin therapy. While people did reference offers of self-help information or group sessions, this was either seen as insufficient:

. . .if you’re struggling, there’s like these videos online. . . on their website or something, they were useless. . . it was too general. . . so the information I can find from anywhere. . .. [P.5]

The amount of time given per session was often seen as insufficient and as such, this posed a challenge for service users:
. . .only having like half an hour session. . .I think with the treatment that I had because it was half an hour, she had to follow a very rigid structure. . .And that just felt like it took up a lot of time [P.3]
 
It was often the case that service users felt they needed more sessions or that they had not managed to work through everything they had wanted to:
. . .I guess it’s not, you know, a longer process. . .it’s not a program that’s meant to continue along with you. So, I guess there’s very much like goals that you intend to complete throughout the- the end of the program, but you know, obviously mental health issues like, continue. [P.10]

Service users appreciated when they were given the option of longer or additional sessions

We were supposed to stop at six [sessions], but I wasn’t feeling very mentally well, so we extended to seven. . . [P.8]

Disquiet at forced revisiting of painful memories
Some of the most common challenges expressed by service users related to their own personal challenges of therapy, such as the fact that talking about their mental health problems was difficult in itself:
In terms of the help for me it’s been OK, the only thing I would say that could be negative is just that the actual program itself like there are some parts that become difficult because of the nature of what is being spoken about. . . I think it’s more like revisiting memories I didn’t really want to revisit. That was the hardest part of it. [P.4]
 
Arundell et al (2024) concluded ‘Service users should be made to feel comfortable and confident in requesting additional support where they feel it is needed so that this can be considered as part of their treatment package’. 
 
At each session two psychometric tests are administered, the results determine the nature of treatment. Arguably NHS Talking Therapies has become de facto an Artificial Intelligence operative but the Arundell et al (2024) paper also cited the comments of some clients about the warmth of some therapists. The clients were all female and from ethnic minorities but felt no cultural adaptations to their treatment had been  necessary. But no data is provided on outcome.

Dr Mike Scott

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NHS Talking Therapies Glaring Failures, Are Highlighted By A Focus On One of The Long-Term Conditions It Targets

CBT is hailed as effective treatment for long-term conditions (LTCs) such as Irritable Bowel Syndrome (IBS). The latter is posited as being maintained by excessively negative cognitions. NHS Talking Therapies, purportedly, provides access to effective treatment for this condition. But this is yet another NHS Talking Therapies myth.

Minimal Access

The prevalence of IBS is between 5 and 20%, and given an adult population of 30 million in England, one would expect (at 10%) 30 X 105 sufferers annually. Thus 3 million is the potential pool of IBS sufferers that could present at NHS Talking Therapies. The service receives approximately 1 million referrals a year and therefore one could expect 100,000 sufferers from IBS to present to NHS Talking Therapies a year, But the latest data from NHS Digital and a response to a Freedom of Information Request (FOI) that I received in June 2024. suggest that approx. 200 present each year, so that it is seeing just 1 in 500 of IBS sufferers. Thus, it cannot be said to be meaningfully provide access to IBS sufferers.

Disengagement

Further, for every 2 people having one assessment/treatment session, only 1 person has 2 or more treatment sessions. The Service is having a serious engagement problem with IBS sufferers.

No Evidence of Recovery

Yet for those who have 2 or more sessions it claims a 50% recovery rate, but this is based on using the PHQ-9, a self-report depression questionnaire as an outcome measure. It can scarcely be taken to measure the severity of IBS. 

Dubious Non-Friendly Model

CBT treatment for long-term conditions (LTCs) is predicated on the assumption that difficulties are maintained by excessively negative cognitions. Little wonder that IBS sufferers have a ‘thanks, but no thanks’ response to engaging with NHS Talking Therapies.

Dr Mike Scott

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How Not To Be A CBT Therapist?

‘CBT, CBT everywhere and not a drop to drink’. It has become common currency, but how often do you see it making a real-world difference to a person’s life? Therapists are likely to keep in mind, a ‘case’ were it has worked, recalling it in great detail to keep motivated. They may via the National Networking Forum, share ‘best practice’ with other CBT therapists, exchanging details of their hallmark case. Thereby, fostering the illusion that it is routinely effective.

But even the randomised controlled trials (rcts) of CBT for depression and the anxiety disorders, whose protocols are recommended by the National Institute for Health and Clinical Excellence (NICE), depict the results in terms of differences in average scores between those who have CBT and those who do not. It is not at all clear from the rcts, what proportion of people have a lasting recovery with CBT. However, the NHS Talking Therapies Manual takes the rcts as demonstrating a 50% recovery rate. This has been the basis on which the Service for adults and children has been funded to the tune of £2 billion a year. But there is no empirical evidence of a translation of the results of the rcts to routine practice. There has been no publicly funded independent assessment of NHS Talking Therapies.

As an Expert Witness to the Court I assessed 90 people who had been treated by NHS Talking Therapies, Scott (2018) and found that only the tip of the iceberg recovered. The results were the same whether they were treated before or after a personal injury. My assessment was based on the use of a ‘gold standard’ diagnostic interview, the most reliable metric in a Court of law. By contrast NHS Talking Therapies own claims are based on changes on two psychometric tests (PHQ-9 and GAD-7) over time. If this data was presented in Court, the Barrister would likely ask “is it not the case that people come to you at their worse, so that there will be some change, ‘time heals’?”, with a follow-up ” like members of the jury I do not doubt that people are pleased with your attention and that you offer hope, but there is no evidence that the Service is responsible, for the alleged recovery?” and “can you please explain, to the Court, why this level of funding is necessary?”.

Such cross-examination of the data does not take place either within the lead organisation for CBT, The British Association for Cognitive and Behavioural Therapy (BABCP) or within NHS Talking Therapies sponsored events. The British Psychological Society (BPS) has been happy to validate courses for low intensity CBT, in a rush to extend the empire of psychological therapy, without the methodologically sound database that high intensity programmes were based on, see Scott (2009) Simply Effective Cognitive Behaviour Therapy, London: Routledge.

Dr Mike Scott