The Cost of IAPT Is At Least Five Times Greater Than Claimed

The British Medical Journal has just published the following letter of mine online with the above title:

‘Six years ago a News headline in the BMJ proclaimed ‘Increasing access to psychological therapies will cost NHS nothing’ BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e4250, citing a report of Lord Layard  of the Mental Health Policy Group of the Centre for Economic Performance http://cep.lse.ac.uk/_new/research/mentalhealth/default.asp, that claimed ‘after an average of 10 sessions half the people with anxiety conditions will recover, most of them permanently, and half the patients with depression will recover’ .  Far from being substantiated an independent assessment by Scott (2018), http://journals.sagepub.com/doi/pdf/10.1177/1359105318755264, using a standardised diagnostic interview, suggest a 10% recovery rate. This represents a five-fold increase of the cost of treatment per cured person.

The progenitors of IAPT, Clark and Layard in their book Thrive (2015) claim that the cost of treatment in IAPT is £650 per person, for people having attended 2 or more treatment sessions.  This leaves out of account the 40% of its clients who attend only one treatment session [IAPT (2018)] and the costs of the initial assessments which totalled £92 million in 2016-2017, with total costs of £367,219,192 in that period.  This means that the true cost of IAPT is at least 5 times greater than alleged, all without any government funded independent audit. Further average session attendance for those ‘treated’ in IAPT is 6.6 [IAPT (2018)] not the average of 10 sessions that Lord Layard deemed necessary, so that the average patient in fact receives a sub-therapeutic  dose of treatment.

In 2012 Lord Layard claimed ‘the average improvement in physical symptoms is so great that the resulting savings on NHS physical care outweigh the cost of the psychological therapy’. This claim remains unproven and what limited evidence is available points in the opposite direction. How do Clinical Commissioning Groups justify paying such inflated sums? how can they be sure another agency could not achieve the same for less? how do they know that GPs simply tracking clients with depression and anxiety disorders would not achieve the same outcomes? NHS England should surely advise CCG’s to ask searching questions and organise a long overdue government funded independent audit of IAPT focusing on real world outcomes, such as loss of diagnostic status..

BMJ (2012) ;344:e4250 Increasing access to psychological therapies will cost NHS nothing, says report

Clark, D.M and Layard, R (2015) Thrive: The Power of Evidence-Based Psychological Therapies London: Penguin.

IAPT (2018) Psychological Therapies: Annual report on the use of IAPT services England, 2016-17 Data Tables. NHS Digital: Community and Mental Health Team.

Mental  Health Policy Group of the Centre for Economic Performance (2012) How mental health loses out in the NHS.   http://cep.lse.ac.uk/_new/research/mentalhealth/default.asp.

Scott, M.J (2018) IAPT: The Need for Radical Reform. The Journal of Health Psychology, 23, 1136-1147.

 

Dr Mike Scott

The Annihilation of The Therapeutic Relationship

The therapeutic relationship has withered under the blistering sun of IAPT. The latest IAPT annual report (2018) shows that 40% of clients attend only one treatment session, with the average client attending just 6 sessions. The therapeutic relationship needs the space of at least 10 sessions to flower according to NICE guidelines.  For assessed only referrals 43% were deemed suitable but declined treatment , 23% were deemed not suitable  and only 9% discharged by mutual agreement (IAPT 2018).

 

 

 

I’ve just edited the proofs of my contribution to ‘The Therapeutic Relationship In Cognitive Behavioural Therapy’ by Stirling Moorey and Anna Lavender to be published by Sage. The contributors cover all the  disorders and contexts (my own chapter is ‘CBT Delivered in Groups’ written with Graeme Whitfield). Most of the authors are well known and agree on the importance of the therapeutic  relationship. The approach taken in the book contrasts sharply with the practices in IAPT.

 

Dr Mike Scott

Independent Critiques of IAPT – Special Journal Issue Open Access

Independent assessments suggest that IAPT is not making a ‘real world’, socially significant difference to client’s lives, albeit that further research is needed. In the Special Issue of the Journal of Health Psychology for August 2018, ways forward are suggested.

 

 

Contents of Special Section of August 2018 Issue of the Journal of Health Psychology ALL OPEN ACCESS

http://journals.sagepub.com/action/showTocPdf?volume=23&issue=9&journalCode=hpqa

IAPT Under The Microscope David F Marks https://files.acrobat.com/a/preview/d142501a-6727-4002-b1c6-9222174610de

Improving Access to Psychological Therapies (IAPT) – The Need For Radical Reform              Michael J Scott

http://journals.sagepub.com/doi/pdf/10.1177/1359105318755264

The diagnosis is correct but National Institute of Health and Care Excellence are part of the problem not the solution Sami Timimi

http://journals.sagepub.com/doi/pdf/10.1177/1359105318766139

Attempting to reconcile large differences in Improving Access to Psychological Therapies recovery rates Scott H Waltman http://journals.sagepub.com/doi/pdf/10.1177/1359105318767158

Medical approaches to suffering are limited, so why critique Improving Access to Psychological Therapies from the same ideology James Binnie 

http://journals.sagepub.com/doi/pdf/10.1177/1359105318769323

Transforming Access To Psychological Therapies Michael J Scott 

http://journals.sagepub.com/doi/pdf/10.1177/1359105318781873

 

Dr Mike Scott

 

 

Clinical Commissioning Groups Fail To Check Compliance With Informed Consent – Have You Been Affected?

Clinical Commissioning Groups (CCG’s) fund IAPT (Improving Access to Psychological Therapy Services), but have failed to ensure that mental health sufferers are not given the cheapest option, guided self-help (GSH), without being informed of its poor performance compared to regular therapy. GSH is the most commonly proferred service by IAPT and its’ usage has breached informed consent. As Pim Cuijpers https://doi.org/10.1111/cpsp.12238 has observed ‘A self-help intervention cannot replace more usual  forms of psychological treatment and this should be made clear from the beginning’. CCG’s are risking legal action from patients given the cheapest treatment option without explanation of alternative treatments, risks and benefits.  There is a pressing need for CCG’s to seriously appraise IAPT and not blindly fund it because ‘it is the only show in Town’.

The response of CCG’s to any criticism of IAPT is typified by the letter below that I received from the

Liverpool CCG, published as an appendix in ‘Transforming IAPT’

https://www.dropbox.com/s/ie4yg6hgmt5fybw/EDITED%20Transforming%20IAPT.docx?dl=0https://doi.org/10.1177/1359105318781873

in the August issue of the Journal of Health Psychology

 

Footnote: In earlier work Cuijpers

https://www.dropbox.com/s/3zgy50ub5s5q1yx/Lewinsohn%27s%20Coping%20with%20Dep%20Meta-Analyses.pdf?dl=0

has noted that the effect size for GSH  for depression is small 0.28 compared to 0.6 or more (large to moderate) for the regular face to face therapy.

 

Dr Mike Scott

‘What, If Anything, Is Beyond The Glitz Of IAPT?’ Asks Journal Editor

‘IAPT Talking Therapies All Glitz and No Substance?’  is the title of a Press Release from the Editor of the Journal of Health Psychology, Dr David Marks, The Press release reads:

 

 

‘The Journal of Health Psychology is calling for an urgent independent review of patient recovery rates
with the NHS ‘Improving Access to Psychological Therapies’ (IAPT) talking therapies programme.

A recent study by Dr. Michael Scott revealed that only one in ten mental health patients actually
recovered (http://journals.sagepub.com/doi/full/10.1177/1359105318755264).

Now JHP editor, Dr David F Marks, is calling for IAPT recovery rates to be closely scrutinized. He
wants solid evidence that patients who have recovered stay well over the long term.

Michael Scott’s study found that overall just 9.2% of patients recovered with IAPT therapies. There is
an enormous gap of 40% between these findings and IAPT’s claimed recovery figure.
The study’s recovery rates were: Post-Traumatic Stress Disorder – 16.2%, depression – 14.9%, other
mental disorders including anxiety – 2.2%.

Dr Scott, Consultant Psychologist and Expert Witness to the Courts, suggested “a pressing need to reexamine…the service”. IAPT’s economic model hinges on good recovery rates and high recruitment.
The contributors to this Special Issue of the journal, “IAPT Under the Microscope”, have all expressed
doubts about the veracity of IAPT’s recovery claims. They agree that there’s a need for an independent
assessment of the type that a drug treatment would require before being approved for use.
The theory is that better mental health will lead to fewer physical health problems so that patients will
need less care. High recovery rates should then yield the promised hefty ‘efficiency’ savings to the
physical healthcare budget that will pay for the IAPT service.

The IAPT spotlight is on patients with ‘medically unexplained symptoms’ (MUS) and ‘long-term
conditions’ (LTCs) such as diabetes and COPD. This expansion into areas beyond its already
questionable expertise is likely to be clinically risky. Experts and patients are worried about the motives behind this and concerned that a mental health diagnosis will allow providers to restrict access to healthcare and other benefits. Can these therapies really reduce patients’ physical problems and their need for care, or is this an NHS version of a ‘hostile environment’?

The programme continues to grow as more local therapy services are rolled out across England. IAPT
aims to enrol over a million patients per year but the system is already creaking under the strain.
In his Editorial, Dr Marks proposes an open debate about England’s flagship IAPT project that has so
far cost the taxpayer around £1 billion. He calls for an independent, expert review to determine if IAPT
is likely to reap the promised rewards or asks if is it all glitz and no substance?

Notes to editors

Marks, D.F. (Ed.) (2018). “IAPT Under the Microscope” published online and in print on 26 July 2018.
http://journals.sagepub.com/home/hpq [see copy attached to email]

Scott, M.J. (2018). Improving Access to Psychological Therapies (IAPT) – The Need for Radical
Reform. Journal of Health Psychology, http://journals.sagepub.com/doi/full/10.1177/1359105318755264

Contact

Dr Michael J Scott, author of the IAPT study, is available at: 07580 644 038
michaeljscott1@virginmedia.com

Dr David F Marks, Editor of the Journal of Health Psychology, is available at: 07930 753 206 ;
editorjhp@gmail.com

 

Dr Mike Scott

IAPT Under The Microscope

Dr David Marks, Editor of the Journal of Health Psychology writes in the latest issue, https://doi.org/10.1177/1359105318781872, ‘England’s flagship ‘Improving Access to Psychological Therapies’ (IAPT) service has cost around £1 billion

 

yet Scott’s (2018a) study suggests that only 9.2% of IAPT patients recover. This leaves an enormous gap of 40.8% between the observed recovery rate and IAPT’s claimed recovery rate of 50.0%. The spotlight is on patients with ‘medically unexplained symptoms’ (MUS) and ‘long-term conditions’ (LTCs) such as ‘diabetes, COPD and ME/CFS, yet there is no way of knowing whether IAPT is capable of yielding the promised rewards or English patients are being sold an expensive pup. An urgent independent expert review of IAPT recovery rates is necessary to answer this question’.

Contents

Special Section: IAPT Under the Microscope
IAPT under the microscope 1131
David F Marks

Improving Access to Psychological Therapies (IAPT) – The Need for Radical Reform 1136
Michael J Scott

The diagnosis is correct, but National Institute of Health and Care Excellence 1148
guidelines are part of the problem not the solution
Sami Timimi

Attempting to reconcile large differences in Improving Access to Psychological 1153
Therapies recovery rates
Scott H Waltman

Medical approaches to suffering are limited, so why critique Improving Access 1159
to Psychological Therapies from the same ideology
James Binnie

Transforming Improving Access to Psychological Therapies 1163
Michael J Scott

Dr Mike Scott

Advice to the National Audit Office, ‘Gardening Is Cheaper Than Inept IAPT’

My independent audit of IAPT suggests a 10% recovery rate https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0.

A year ago the National Audit Office invited submissions for its investigation into IAPT, and has to date decided not to make its’ conclusions public. Whither transparency and the use of public funds? They failed to advise that gardening might be a better use of the public purse, then at least we would get tomatoes.

 

Dr Mike Scott

Guided Self-Help In IAPT Breaches Informed Consent

‘That self-help is not a regular treatment should be clear from the beginning…A self-help intervention cannot replace more usual forms of psychological treatment and this should be made clear from the beginning’ so writes Pim Cuijpers in the most recent issue of Clinical Psychology Science and Practice

https://www.dropbox.com/s/4d9z23p1xttv7nl/Cuijpers-2018-Clinical_Psychology%253A_Science_and_Practice%20ethics%20guided%20self-help.pdf?dl=0 ,

but it never is in IAPT.

 

Cuijpers points out that guided self-help (GSH) for depression has a small effect size around 0.28 and this is substantially less than the O.6 or higher of traditional psychological treatments https://www.dropbox.com/s/3zgy50ub5s5q1yx/Lewinsohn%27s%20Coping%20with%20Dep%20Meta-Analyses.pdf?dl=0.

Further the impact of GSH may be even less when compared to active control conditions as opposed to the common comparisons that have been made with inert waiting lists. In addition a diagnostic interview has been used in only at most half of the GSH studies.

It is unethical not to let clients know that what they will most likely receive initially in IAPT is a substandard treatment. The risks and benefits of any procedure need to be clearly spelt out for informed consent. Service users are entitled to provider track record information. There would appear to be grounds for complaint from former IAPT clients, whether to NHS England or perhaps via a lawyer. The NHS guidance on consent to treatment states ‘the person must be given all the information in terms of what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment doesn’t go ahead’.

Dr Mike Scott

 

Transforming Improving Access to Psychological Therapies

The three commentaries on my paper ‘IAPT – The Need for Radical Reform’ are agreed that Improving Access to Psychological Therapies cannot be regarded as the ‘gold standard’ for the delivery of psychological therapy services. Furthermore, they agreed that Improving Access to Psychological Therapies should not continue to mark its ‘own homework’ and should be subjected to rigorous independent evaluation scrutiny. It is a matter for a public enquiry to ascertain why £1 billion has been spent on Improving Access to Psychological Therapies without any such an independent evaluation. What is interesting is that nocommentary has been forthcoming from the UK Improving Access to Psychological Therapies service nor have they shared a platform to discuss these issues. It is regrettable that the UK Government’s National Audit Office has chosen, to date, not to publish its own investigation into the integrity of Improving Access to Psychological Therapies data. Openness would be an excellent starting point for the necessary transformation of Improving Access to Psychological Therapies.

Dr Mike Scott

Subjective Measures Are Insufficient – Lessons from CBT for ME/CFS

The  results of the PACE trial of CBT plus graded exercise for CFS have just been confirmed by a review of 5 Dutch studies

https://www.researchgate.net/publication/322956569_An_analysis_of_Dutch_hallmark_studies_confirms_the_outcome_of_the_PACE_trial_cognitive_behaviour_therapy_with_a_graded_activity_protocol_is_not_effective_for_chronic_fatigue_syndrome_and_Myalgic_Encep , the author’s concluded ‘ Improvements on subjective measures (self-report questionnaires), which are sensitive to placebo effects, response bias, buy-in effects and other psychological effects , isn’t reflected by an improvement in objective measures’. This was illustrated by the finding that 32% of the patients in the non-intervention group reported clinically significant improvement afterwards.

 

IAPT justifies itself wholly in terms of changes on psychometric tests, alleging a 50% recovery. However there has been no independent examination to determine the proportion totally free of symptoms by the end of treatment. My own work in fact suggests just a 10% recovery,https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0 . In mid July the Journal of Health Psychology is publishing an Open Access Special Issue ‘IAPT Under the Microscope’ in which these issues are explored further, with 4 contributors, including myself and a missive from the Editor, Dr David Marks.

 

Dr Mike Scott