Clinical Commissioning Groups Decade of Neglect In Auditing Mental Health Pathway

no Clinical Commissioning Group has been compliant with NICE’s (2011) 1.5.1.2 https://www.nice.org.uk/guidance/cg123 injunction for them to audit and review local mental health pathways. Instead, the  CCGs have left it to the Improving Access to Psychological Therapies (IAPT) programme to mark their own homework. NHS England has turned a blind eye. Can there be a better example of institutionalised bias against mental health patients?

The National Institute for Health and Clinical Excellence (NICE) document https://www.nice.org.uk/guidance/cg123 (2011) also advocates a stepped care model that ‘provides the least intrusive  and most effective intervention first’. But this creates a conundrum in that, clearly the least intrusive interventions include, guided self-help, computerised CBT and psychoeducation groups, what would be deemed low intensity interventions in IAPT. However, the NICE recommended treatments for specific disorders, are recommended in a dosage that would be incompatible with a low intensity intervention. It is only the high dosage interventions that have been credibly systematically evaluated in randomised controlled trials. Contrary to the assertion of Boyd et al (2019) https://doi.org/10.1371/journal.pone.0214715 there is not ‘sound evidence for the efficacy of low intensity interventions’.  The methodological quality of the studies that form the basis for NICE’s recommendation for specific disorder treatments is much stronger than the foundation for the low intensity recommendations. Thus to provide ‘the most effective intervention’ first would mean jettisoning low intensity interventions and herald the demise of the stepped care model!

The mnemonic PICOT has been advocated by NHS England (2013) Finding the Evidence https://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwj5_-fAhbn0AhXDiVwKHSgdDnYQFnoECBgQAQ&url=https%3A%2F%2Fwww.england.nhs.uk%2Fwp-content%2Fuploads%2F2017%2F02%2Ftis-guide-finding-the-evidence-07nov.pdf&usg=AOvVaw3-7g7wSw9WFJhtWaS-gBdX to help clinicians distinguish what is an evidence-based treatment and  what is not. The P refers to the  patient/problem/population studied, I the intervention/exposure of interest, C the comparison condition, O for outcome and T the time frame. The low intensity interventions fall at each hurdle. With regards  to P the patient population is poorly specified, with reliance on a self-report measure rather than a ‘gold standard’ diagnostic interview. The intervention used, I, is fuzzier in low intensity interventions with no indication as to how it is adapted to the needs of the individual. The comparison conditions, C are invariably waiting list controls in low intensity interventions, but patients on waiting lists do not expect to get better, the appropriate comparison is an active control group e.g attendance at a shyness group to learn from each other what works best for them. The outcome, 0, in low intensity interventions is always a change on a self-report measure, it is never complemented by an independent evaluation of the diagnostic status of the person. Finally T, there is no indication in the low intensity studies of the duration of gains i.e what proportion of those who have recovered go on to maintain their gains. Whilst not all rct’s of  high intensity interventions clear the PICOT hurdles about half do and these interventions merit a strong recommendation. These studies are qualitatively different to the low intensity studies.

 

 

It is a source of concern that the manufacturers of Silver Cloud, a computerised CBT programme, is the sponsor of a recently publicised IAPT training day. 

 

Dr Mike Scott

 

6 thoughts to “Clinical Commissioning Groups Decade of Neglect In Auditing Mental Health Pathway”

  1. Interesting Michael, it seems SilverCloud is being taken over by the US Company Amwell, whose goal is ‘automated companionship’ according to its CEO Roy Schoenberg. I don’t deny that computerised CBT can be an adjunct to treatment, but only the inhabitants of Huxley’s, Brave New World would claim that ‘automated companionship’ is a solution to mental health problems. SilverCloud has never been subjected to independent investigation using ‘gold standard’, diagnostic interviews and with assessors blind to treatment allocation. It is not an evidence-based treatment. Unsurprisingly this international company has spotted that there are rich pickings to be had via IAPT and has funded training days. I was going to meet up with friends in my local Costa for coffee this afternoon, but perhaps there is another key I can depress on my keyboard for ‘automated companionship’ instead and save the cost! IAPT’s gullibility is breathtaking.
    Mike

  2. A piece of historical information might be useful regarding low intensity interventions:
    I was part of a steering group that was supposed to be examining the evidence for them, yet prior to any examination of the evidence, a senior member of the group announced at a national conference that they were effective. Following this assertion, plans were put in place to develop trainings nationally, all without evidence that such interventions worked. It always struck me as deeply ironic that a supposedly evidence based national project was structured around something for which no decent research existed.

    1. I’d be really interested in any details that u can give Geoff, but realise this might put you in a difficult position.
      Thanks and take good care
      mike

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