If you are anxious or depressed and wish to seek psychological help on the NHS you are most likely to be offered low intensity CBT (LICBT) via the Government funded Improving Access to Psychological Therapies (IAPT) service. But don’t expect it to make a real world, socially significant difference to your life. Two just published studies, one focussing on Adults [Ali et al (2017)] and the other on children [ Cresswell et al (2017)], highlight the paucity of evidence in support of this cost-cutting approach.
Ali et al (2017) looked at low intensity IAPT clients who had remitted by the end of treatment and found that half had relapsed within 12 months. Far from suggesting that this sounds like a ‘failed experiment’ the authors suggest that the programme should be simply amended to include relapse prevention despite stating earlier in the paper that relapse prevention was part of the protocol! Some weeks ago I wrote a Rejoinder to the paper which is currently being considered for publication in Behavior Research and Therapy. Interestingly the Research Digest of the Psychologist for June 13th 2017 headlines its’critique of the Ali et al (2017) paper ‘False Economy?’
Cresswell et al (2017) looked at the effectiveness of parent guided CBT self-help vs parent guided solution focussed self-help in children aged 5-12 with an anxiety disorder and concluded that they were equally effective but the latter was more costly. In an accompanying commentary Stallard (2017) heralds the study as marking the way forward for children’s IAPT. But there is no comment by him that a) the outcome measure used, the Clinical Global Impressions of Improvement was designed for use with regards to the trajectory of specific disorders, it was not intended as an across the board measure and is of doubtful validity in this study, b) there was no waiting list control group – children’s debility is likely to be particularly transitory c) that the study did not include any children with OCD or PTSD and in the CBT arm 50% had generalised anxiety disorder and 25% a specific phobia – generalising from this study to children with anxiety disorders is therefore problematic or d) that 40% of parents in the CBT arm had higher education, this is unlikely to be the case in many areas.
There are conflict of interest concerns with both papers Shehzad Ali heads the Northern IAPT Practice Research Network and Paul Stallard is joining Cathy Cresswell in running a randomised controlled trial. Demand of MPs, GPs and Clinical Commissioning Groups that psychological therapy services make a socially significant difference and are independently rigorously evaluated. Remind them there is good news: fully implemented CBT protocols result in over 50% of clients with depression and anxiety disorders no longer meeting diagnostic criteria for the condition by the end of treatment.[Scott (2017)].
Dr Mike Scott
Ali et al (2017) How durable is the effect of low intensity CBT for depression and anxiety? Remission and relapse in a longitudinal cohort study Behaviour Research and Therapy 94 (2017) 1-8
Cresswell, C et al (2017) Clinical outcomes and cost-effectiveness of brieg guided parent-delivered cognitive behavioural therapy and solution-focused brief therapy for treatment of childhood anxiety disorders: a randomised controlled trial. Lancet Psychiatry published online May 17th 2017
Scott M.J (2017)} ‘Towards a Mental Health System that Works’ London: Routledge
Stallard, P (2017) Low-intensity interventions for anxiety disorders. Lancet Psychiatry published online May 17th 2017