Mental Health Patients and GPs Caught In IAPT’s Revolving Door

30% of GP referrals to the Improving Access to Psychological Therapies (IAPT) service do not attend, and of those who attend for treatment, 40% do so for only one session [Pulse November 2nd 2018 Home Analysis NHS structures Revealed: How patients referred to mental health services end up back with their GP]. The GP is left to cope with this haemorrhaging , with no input from Clinical Commissioning Groups (CCGs) to rectify matters.  The CCGs are complicit in IAPT ‘cherry picking’ clients, refusing clients under another service, such as substance misuse or an eating disorder.  Further the CCG’s do not bat an eye when IAPT claims to have met its’ target of a 50% recovery rate.  They miss the point that there has been no publicly funded  independent audit of IAPT.  They are blissfully ignorant that using an independently administered standardised semi-structured interview (SCID) only the tip of the iceberg (9.2%) recover Scott (2018) https://doi.org/10.1177%2F1359105318755264.

Evidence based practice involves an integration of best research evidence, clinician expertise and patient’s preferences [ NHS England document ‘Finding the Evidence’ November (2013)].

There are no randomised controlled trials, using a blind evaluator, of IAPT’s modal, low intensity treatment.  Making  the ‘best research evidence’ leg unstable.  GPS do not audit the effect of IAPT on their patients and so their clinical expertise in dealing with these patients is questionable.  Shared decision making is an integral part of  eliciting patient preferences. But in IAPT clients are usually discharged when they have had the pre-determined number of sessions and/or when their score on a self-report measure falls below a certain cut-off.  There is no credible elicitation of client’s preferences. All legs of the evidence based practice stool have fault lines, and it collapses under IAPT’s weight. The Agency is a prime exemple of failed evidence based practice.

Dr Mike Scott

The Department of Health Has Failed To Regulate Routine Mental Health Services

Improving Access to Psychological Therapies (IAPT) services are out of bounds to Care Quality Commission inspection.  In 2016 the National Audit Office (NAO) asked the Department of Health to address this issue and it has done nothing.  The Department sets the agenda and budget for NHS England, who in turn do the same with Clinical Commissioning Groups to determine local provision of services. But NHS England staff are lead players amongst service providers, these conflicts of interest exacerbate the parlous governance of IAPT. There is a need for Parliament to step in and take the Department of Health to task.  

 

Whilst no one doubts the importance of improving access to psychological therapies, it was remiss of the NAO in 2016 to take at face value IAPT’s claim that it had the appropriate monitoring measures in place.  Incredulously the NAO accepted at face value IAPT’s claim that it was achieving a 45% recovery. It is always tempting to look only as far as evidence that confirms your belief. But it is equally important to consider what type of evidence would disconfirm your belief. The NAO has failed to explain why it has not insisted on independent scrutiny of IAPT’s claims. 

The The Improving Access to Psychological Therapies (IAPT) programme has exercised a confirmatory bias in its’ audit by focussing only on self-report responses on  psychometric tests (the PHQ9 and GAD7). The service has never looked at a categorical end point, such as whether a person lost their diagnostic status as assessed by an independent evaluator using a standardised diagnostic interview.

Organisations, are inherently likely to be self-promoting and will have a particular penchant for operating, not necessarily wholly consciously, with a confirmatory bias. It is for other stakeholders, NHS England, Clinical Commissioning groups, MPs, the media, Charities and professional bodies (BABCP  and BPS) to hold IAPT to account. For the past decade they have all conspicuosly failed to do so. How have IAPT evaded critical scrutiny, despite the taxpayer having paid £4billion for its’ services? Friends in high places is the most likely answer. I have called for an independent public inquiry for years and will continue to do so  but there is likely to be an echo of a deafening silence as the only beneficiary would be the client with mental health problems.  

Dr Mike Scott

A Conflict of Interest Between NHS England and IAPT

 

the Improving Access to Psychological Therapies (IAPT) pantomine is likely to continue, with Dr Adrian Whittington, National Lead for Psychological Professions, NHS England  and IAPT National Clinical Adviser about to chair a Conference with the leading light of IAPT, Professor David Clark for IAPT staff.      IAPT afficionados seem inherently incapable of understanding what constitutes a conflict of interest, see forthcoming issue of the British Journal of Clinical Psychology, ‘Ensuring IAPT Does What It Says On The Tin’. https://doi.org/10.1111/bjc.12264.

page1image32572160 page1image32571584 page1image32572352 page1image32572544 The Information Standard Guide

Finding the Evidence

A key step in the information production process

November 2013

Caroline De Brún

NHS England  should reflect on their own document published in 2013 ‘Finding the Evidence’ in which clinicians are asked to seek the ‘best research evidence’ by looking at how an intended treatment has fared compared to a credible alternative. Taking the IAPT service as the intended treatment there has never been a comparison with a credible alternative. IAPT cannot be considered  a repository of ‘best evidence’

The power holders, wish to believe their fairy tale ‘we are committed to mental health, we have shown this in supporting our world beating IAPT service, as far as possible we will fund expansion of the service, we have broken new ground’ and in small print ‘it is not politically correct to say other and we are too busy  with the pandemic/physical health to critically analyse IAPTs data’. But this is a dangerous story offering no protection for the mental health sufferer. It is time that sufferers are seen as ‘vulnerable’ people and offered societal protection.

IAPT therapists do not ask the client,  at the end of treatment, whether they are back to their old selves again. Outcome is determined by the Genie that arises out of the psychometric test lamp that IAPT polishes incessantly.

The Genie could be pressed ‘how does low intensity CBT work?’  A coughing and spluttering might ensue. It is known that CBT works for the depression and anxiety disorders, using the specific cognitive model for those disorders. But there is no evidence that simply describing the reciprocal interactions of cognition, emotion, behaviour and physiology, then targeting   one or more of them leads to an evidence supported treatment. It is a fundamentalist translation of the treatments conducted in the randomised controlled trials of depression and the anxiety disorders. It is a translation born of the exigencies of the situations, such as vast monies available for treatment, but it is akin to using a religious belief system for political purposes.

 The CBT protocol for panic disorder is entirely dependent on David Clark’s model (2020) of catastrophic misinterpretation of bodily sensations perpetuating the symptoms of panic https://doi.org/10.1007/s10608-020-10141-0. None of the procedures in the protocol would make sense without reference to his model. 

A cognitive model of a disorder is the nucleus around which orbit all the procedures of a protocol. Beck enshrined this in his theory of cognitive content specificity, that disorders are distinguished by their  different cognitive content and connive profiles see Baranoff, J., & Oei, T. P. S. (2015). The cognitive content-specificity hypothesis: Contributions to diagnosis and assessment. In G. P. Brown & D. A. Clark (Eds.), Assessment in cognitive therapy (p. 172–196). The Guilford Press, and Eysenck and Fajkowska (2018) https://doi.org/10.1080/02699931.2017.1330255.

But the procedures in low intensity CBT have no nucleus. For example the strategies in Williams et al (2018) doi: 10.1192/bjp.2017.18 Living Life to The Full classes ‘covering key CBT topics such as altered thinking, behavioural activation, problem-solving and relapse prevention’,  are not derived from any specific cognitive model of disorder – they are the equivalent of displaced electrons, the atoms have no credible name and the targets ill defined. For example in the Williams et al study (2018) the target is ‘low mood and stress’, the latter has no specific cognitive content or cognitive profile.   If it is not known how a psychological therapy achieves its goal then the therapy itself cannot be considered evidence supported. There has to be a plausible scientific explanation of the mechanism of change. The low intensity cbt protocols represent an ad hoc usage of cbt techniques, it is impossible to distil the mechanism of change, if any, in such a collage.  In this respect the low intensity interventions are found wanting, they are poor translations of the protocols in the ‘gold standard’ randomised controlled trials,  they are advocated in a fundamentalist way by IAPT, driven by perceived economy than any considered view of effectiveness.

Dr Mike Scott

 

‘Intensive Care PTSD’

this was the banner  headline on the BBC News today, January 13th 2021. It followed the announcement of a study by Prof Neil Greenberg, which revealed that staff had been ‘traumatised’ by the first wave of the pandemic. This in turn led for Paul Farmer Chief executive of MIND to call for ‘the right support at the right time’ on BBC radio 4 today. The Government has promised an extra £15 million so that extra support can be given.  But what sort of support?

In the press release accompanying publication of his study in the journal Occupational Medicine, Professor Greenberg notes ‘Further work is needed to better understand the real level of clinical need amongst ICU staff as self-report questionnaires can overestimate the rate of clinically relevant mental health symptoms’. His study was based on a web survey of ICU staff about half of whom responded, about half whom met the ‘threshold’ for PTSD, severe anxiety or problem drinking. There is a clear need to go beyond self-report measures.

I am currently writing a book ‘Personalising Trauma Treatment: reframing and reimagining’ to be published by Routledge. In this work I suggest that the initial conversation with trauma victims   should include ‘Gateway Diagnostic Interview Questions’ , with regard to Covid an appropriate subset would be:

Depression (evidence that at least one of the answers to the following questions is in the affirmative)

1. During the past month have you often been bothered by feeling, depressed or hopeless?

2. During the past month have you often been bothered by little interest or pleasure in doing things?

 

Panic Disorder

1. Do you have unexpected panic attacks, a sudden rush of intense fear or anxiety?

2. Do you avoid situations in which the panic attacks might occur?

 

Post-traumatic Stress Disorder

In your life, have you ever had any experience that was so frightening, horrible or upsetting that, in the past month, you

1. Have had nightmares about it or thought about it when you did not want to?

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

3. Were constantly on guard, watchful, or easily startled?

4. Felt numb or detached from others, activities, or your surroundings?

5. Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the events may have caused?

Evidence that at least three of the answers to the symptom questions above are in the affirmative

Alcohol Dependence (evidence is that the response to the first three of the following questions is in the affirmative)

1. Have you felt you should cut down on your alcohol/drug?

2. Have people got annoyed with you about your drinking/drug taking?

3. Have you felt guilty about your drinking/drug use?

4. Do you drink/use drugs before midday?

Asking GDIQ questions encourages the person to furnish possible examples of the impact of the symptom on their life, so that they feel listened to. Reference can then be made to other  diagnostic symptoms for the particular disorder, to tease out whether there are sufficient impairing symptoms for that disorder, to merit that diagnostic label.  Use of GDIQ’s is part of a conversation, it is not a rapid fire interrogation or checklist. As a supplement to the GDIQ people can be asked whether this is something that they want help with, as they might not want to verbalise that they want to sort the problem out themselves, but are too polite to express this. 

The NICE recommended treatments are diagnosis specific, thus there is a recommendation of trauma focussed CBT for PTSD. But those traumatised by Covid are likely to find it toxic to be pushed to describe in graphic detail the horrors encountered. In my book I argue that this is unnecessary, rather that what is of key importance is to assess what the person takes their memory of being in ICU means about today. It is not the event that causes PTSD but the mental time travel to the worse period and the significance given to it  for today. This approach  is much less challenging for whoever is  accompanying the effected medical staff and family/friends who have seen horrors.

 

Dr Mike Scott

Unnecessary Treatment Is The Rule In IAPT – Due Diligence?

 

The UK Government, Improving Access to Psychological Therapies (IAP) only uses psychometric test screening measures  to assess clients, most commonly the  PHQ9 ( a measure of the severity of depression) and GAD7 (a measure of the severity of generalised anxiety disorder), but other measures are advised for other disorders, such as the PCL-5 for PTSD. A study by Zimmerman and Matia (2001) [The Psychiatric Diagnostic Screening Questionnaire: development, reliability and validity. Comprehensive psychiatry, 42(3), 175–189. https://doi.org/10.1053/comp.2001.23126 ] showed that questionnaire measures that reflect DSM criteria have a roughly 90% sensitivity across major depressive disorder, PTSD, panic disorder, social phobia and GAD, i.e it correctly identifies 9 out of 10 of those who do have one of these disorders. But it identifies only about 60% (specificity) of those who do not have the disorder and for GAD only 50%.  However many more people do not have a particular disorder than have one, leading to unnecessary treatment for many. The National Audit Office should take note of this and re-instate its’ investigation, where is the due diligence with regards to IAPT? £4billion has been given to IAPT!

Depression

In the Zimmerman  and Mattia (2001) study 47.9% of the psychiatric outpatients had major depression. Assuming psychiatric outpatients are a reasonable approximation to the IAPT population, then in a sample of 100 patients approx. 50 would have depression and 50 would not. Of the 50 with depression, 45 would have been correctly identified and treated. However of the 50 who did not have depression only, 30 would have been correctly identified leaving 20 as false positives, candidates for inapropriate treatment. Thus roughly for every two depressed cases appropriately treated one would be inappropriately treated. For depression the appropriate/inappropriate ratio is 2/1 – pretty wasteful.

Generalised Anxiety Disorder

In the Zimmerman Mattia Study 17.5% pf the psychiatric outpatients  had GAD. Thus in a sample of 100 patients approx. 18 would have GAD, of whom 16 would have been correctly identified and treated. But 82 would not have GAD but 50% of them would have been regarded as having GAD meaning that 41 would have been inappropiately treated. Thus for GAD the appropriate/inappropriate ratio is 16/41, so that for every one GAD client treated appropriately 2-3 others are treated inappropriately.

Post-traumatic Stress Disorder

In the Zimmerman and Mattia study 10.5% of the psychiatric outpatients had PTSD. Thus in a sample of 100 clients approx. 11 would have PTSD with 9 being correctly classified and treated. However 89 would not have PTSD of these 62% (55) were correctly classified, meaning that 34 were false positives. Thus the ratio of appropriately treated/ inappropriately treated is approximately 1/4 , for every one treated appropriately 4 are treated inappropriately.

IAPT’s Preposterous Claim On Recovery

Given the ubiquity of unnecessary treatment in IAPT, its’ claim of a 50% recovery rate [IAPT Manual (2019)] is preposterous.  I found a 10% recovery rate Scott (2018) https://doi.org/10.1177%2F1359105318755264, which is much more likely if a body relies simply on a screening instrument.

The Need To Translate Research Methodology Into Routine Practice

Ehlers et al. Trials (2020) 21:355 https://doi.org/10.1186/s13063-020-4176-8 have used the PDSQ to screen for cases of PTSD in their study of therapist assisted treatment for the condition, but have followed the screen up by using a standardised semi-structured interview the SCID to then diagnose PTSD. In this study they have kept a screen in its place and not allowed it free rein as in IAPT.  The IAPT Manual p25 states ‘To ensure that all relevant problems are identified, it is recommended that assessments include systematic screening for each of the conditions that IAPT treats. Standardised commercial screening questionnaire that cover the full range of problems and that can be completed by people before they attend an assessment can be considered ‘ and cites the  PDSQ as an example. But sole use of any screening instrument is very wasteful.

Ehlers et al (2020) have sought to establish whether no more than 4 hours therapist time can make a real world difference to PTSD sufferers lives, a consummation devoutly to be wished, these authors could be well employed helping IAPT get its’ own house in order.

 

Dr Mike Scott

‘Psychometric Testing In Clinical Settings’ – contains a devastating critique of IAPT

this is the title of a Chapter, by Hamilton Fairfax in a book ‘Psychometric Testing’ edited by Barry Cripps in (2017) and published by John Wiley. Fairfax pulls no punches, on the over interpretation of a psychometric test score:

‘These concerns are increased when organisations place value on such scores, and base commissioning and service decisions on them away from the clinical context. Increasingly, such decisions by NHS and private health care providers are made by individuals who are either not familiar with the specifications of services or not sufficiently trained clinically or methodologically to understand the information they are provided with. Instead they are under pressure to ensure services are economically viable; the attraction of a number that purports to measure improvement is obvious. It is possible to manage mental health services in a way that would not be permissible in banking, the military or food production.

One risks accusations of arrogance or pomposity if one’s critique of a management decision is based on the manager’s lack of awareness or training. A strange and unintended consequence of EBP (evidence based practice) is that it provides a heuristic for the uninformed to speak with authority in a way in which many of us would not speak to a mechanic just because we had read a car manual. Stating that something is ‘evidence-based’, whether or not the person knows much about the area being discussed, is often seen as sufficient. It is dangerous to base policy and the survival of clinical services on this level of insight. In outlining this position I do not want to demonise managers or create an equally unhelpful heuristics. Many are well informed, with good clinical experience, but their roles have increasingly alienated them from the realities of practice. Demand and the pressure to be more effective can diminish flexibility and creative thinking, leading to a reliance on quick information such as numbers and ‘evidence’. I speak from personal experience and am aware that these pressures only increase with more responsibilities’.

Hopefully we can manage a better New Year

Dr Mike Scott

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