Ignoring Mental Health Outcomes That Matter

this is a speciality of Government provided services. Studies of the natural history of depression and the anxiety disorders insist on using evidence of enduring freedom from the disorders of                     8-12weeks [Bruce et al 2005https://doi.org/10.1176/appi.ajp.162.6.1179 and Penninx et al (2011) doi:10.1016/j.jad.2011.03.027] as evidence of remission, distinguishing the latter from a new episode of the disorder. This reflects the general public’s understanding of having a disorder or not having a disorder. But inspection of the Government’s Improving Access to Psychological Therapy (IAPT) service reveals no such clarity. Instead funders of services and clients are invited to believe that the latter endorsing a below 10 score on the PHQ9, over the previous two weeks,  is evidence of appropriate treatment. Further the scoring is discussed with the therapist, usually resulting in an exit from the Service when this promised land is reached. But it is entirely a mirage, that suits IAPT’s need to secure funding. The narrow interest of the Service is put above the public good. 

IAPT’s metric ignores the complexity of presentations, client’s may present with depression an anxiety disorder or a combination of the two, each follows their own trajectory [Penninx et al (2011) doi:10.1016/j.jad.2011.03.027]. But there is no reliable identification of who is on what pathway, as IAPT clinicians do not make diagnoses [IAPT Manual (2019)]. It is therefore impossible to match treatment to diagnosis. Further IAPT takes no steps to ensure treatment fidelity i.e the matching of a treatment strategy to a target. 

The mnemonic PICOT has been used by NHS England and NICE to help determine evidence based treatment. The P stands for population  or the problem being addressed. IAPT’s gateway criteria for disorders are scores over 10 on the PHQ9 or over 8 on the GAD7. But what does this tell us about this population? Are they suffering from depression and/or an anxiety disorder? which anxiety disorder? Can there be any certainty that they are not suffering from an adjustment disorder or possibly PTSD? In what way would this population differ from another population that they might resemble? The ‘P’ of the PICOT in IAPT is so fuzzy that it sabotages any pretence by the service to deliver an evidence based treatment (EBT). IAPT has no fidelity  checks, making it impossible to specify the I. IAPT has never attempted to compare its’ service effects with effects of pre-IAPT counselling, thus it has never attempted C a comparison, making it impossible to state the ‘added value’ of its ministrations. IAPT has declared its’ own outcome of interest and measured in its presence, it is not a primary outcome used in any randomised controlled for depression and the anxiety disorders. The selected outcome measure is self-serving. IAPT takes a photo of the client in a 2 week period when with their assistance they appear to be doing well. This is like defendants Insurers taking video footage of client claiming  an acquired injury, with snapshots of him/her going to the shops, sometimes accompanied,  over a 2 week period.  It says nothing of their fitness to persist in a pre-existing manual job. There is no meaningful distilation of the T in PICOT. IAPT’s practice makes it impossible to evaluate the service according to the NHS and NICE recommended PICOT framework.The IAPT data set is insufficient to meet the PICOT criteria above, at each level.

IAPT operates in a pre EBT mode, relying simply on the judgements of practitioners and by reference to the designated ‘Experts’ within the Organisation, oftentimes nominated by the British Association of Cognitive and Behavioural Psychotherapies (BABCP). The ‘nominations’ are not advanced by BABCP’s claim to be the ‘lead organisation’ for CBT, it certainly does not lead to the promised land. My own research Scott M. J. (2018). Improving Access to Psychological Therapies (IAPT) – The Need for Radical Reform. Journal of health psychology, 23(9), 1136–1147. https://doi.org/10.1177/1359105318755264suggests that only the tip of the iceberg recover in IAPT.

The IAPT training courses fail to equip clinicians with the skills to avoid being led astray, making my real world findings of effectiveness or the lack thereof, unsurprising.

 

Dr Mike Scott

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