of those who undergo an initial assessment with the Improving Access to Psychological Therapies (IAPT) Service 40% do not go on to have treatment, and about the same proportion (42%) attend only one treatment session, according to a just published study by Davis A, Smith T, Talbot J, et al. Evid Based Ment Health 2020;23:8–14. doi:10.1136/ebmental-2019-300133. These findings echo a study published last year by Moller et al (2019) https://doi.org/10.1186/s12888-019-2235-z, on a smaller sample, which suggested that 29% were non-starters and that the same proportion attended only one treatment session. Further scrutiny of the data reveals that about 3 out of 4 people drop out of treatment once begun. Unsurprisingly the authors’s independent study, of 90 IAPT clients, Scott (2018) revealed that only the tip of the iceberg (9.2%) recovered DOI: 10.1177/1359105318755264, raising serious questions about why the Government has spent over £4 billion on the service.
What Has Gone Wrong?
Kline et al (2020) consider that at an assessment by a clinician is supposed to: a) provide a credible rationale for the proposed treatment b) detail the efficacy of the envisaged treatment and c) ensure that the clients preferences are acknowledged. IAPT’ assessments fail on all counts, taking these in turn:
a. If the problem is ill-defined e.g low mood/stress it is not clear what rationale should be presented. It is doubtful that a 30-45 minute telephone conversation can provide sufficient space to define the primary problem and other problems/disorders that may complicate treatment. Initial assessments of patients for randomised controlled trials of psychological interventions are typically 90 mins plus, if this is the time deemed necessary to reliably diagnose a patient by a highly trained clinician, how can a much less trained PWP do it in less than half the time? Under time pressure a PWP may consider providing a credible rationale is part of treatment not assessment and in such circumstances it becomes more likely that a client will default.
b. How often do PWPs present clients with evidence on the efficacy of an intervention? Take for example, computer assisted CBT, does the therapist tell the client that only 7 out of 48 of NHS recommended e-therapies have been subjected to randomised controlled trials, ( see Simmonds-buckley et al J Med Internet Res 2020;22(10):e17049) doi: 10.2196/170490 and even in these a gold standard semi-structured diagnostic interview conducted by a blind assessor was not use to determine diagnostic status post treatment, i.e there was no determination of the proportion of clients who were back to their old self after treatment and for how long. Further the e-therapies had average dropout rates of 31%. They are not evidence based treatments in the way the NICE recommended high intensity treatments are. But approximately three quarters Of IAPT interventions (73%) are low intensity first, with 4% stepped up to high intensity and 20% in total receiving a high intensity intervention Davis A, Smith T, Talbot J, et al. Evid Based Ment Health 2020;23:8–14. doi:10.1136/ebmental-2019-300133
c. Client’s preferences are a predictor of engagement in treatment, but how often is a client given a choice between a low intensity intervention and a high intensity intervention. If both options are juxtaposed choice is likely skewed by informing the client that the high intensity intervention has a much longer waiting time.
Defining A Dropout
The generally accepted definition of a dropout is attending less than 7 sessions [see Kline et al (2020) https://doi.org/10.1016/j.brat.2020.103750], it is held that clients attending below this number will have had a sub-therapeutic dose of treatment and are therefore unlikely to respond]. Applying this metric to IAPT’s dataset is difficult as they only report data for those who complete 2 or more sessions and for which the average number of sessions attended is 6, thus the likely dropout rate from IAPT treatment, as most would understand the term, is about 75%. But IAPT has developed its’ own definition of a completer as one who attends 2 or more sessions. This strange definition serves only to muddy the waters on its haemorrhaging of clients. It makes no sense to continue to fund IAPT without an independent government inquiry into its’ modus operandi.
An Alternative Way Forward
Such has been the marketing power of IAPT over the last decade, that professional organisations such as the British Association for Behavioural and Cognitive Psychotherapies (BABCP) and the British Psychological Society (BPS) have sat mesmerised, as the Services fellow travellers have dominated accreditation and training. In ‘Simply Effective Cognitive Behaviour Therapy’ published in (2009) by Routledge, I detailed a very different way of delivering services, that represents a faithful translation of the CBT treatments delivered in the randomised controlled trials (rcts) for depression and the anxiety disorders. Unfortunately it is IAPT’s fundamentalist translation of the rcts that has held sway and has brooked no debate either in journals or at Conferences.
Dr Mike Scott