The National Institute for Health and Clinical Care Excellence (NICE) rightly considers the results of randomised controlled trials in advocating particular psychological therapies, but has not assessed whether, as implemented, they represent an added value compared to previously available therapies. Consider a new drug that is of proven efficacy in randomised controlled trials, NICE would understandably look positively at it, but before recommending it would want to know about side effects and the proportion of people discontinuing use. However NICE seems blissfully unaware that for the psychological treatments that they recommend, when delivered in routine practice, only one half of people tolerate more than one treatment session [Improving Access to Psychological Therapies (IAPT) Annual report 2019-2020 https://files.digital.nhs.uk/B8/F973E1/psych-ther-2019-20-ann-rep.pdf,. But they do know that there is no independent evidence of greater remission since the inception of IAPT – their silence on this point is deafening.
The NICEimpact mental health document (2019) asserts, p4 ‘The IAPT programme offers NICE-recommended treatments’ for common mental health disorders in adults. No it does not and what is worse still is that NICE have never bothered to check. NICE has been simply the voice of the power holders in mental health and not the consumers.
The usual metric employed by NICE is Quality Adjusted Life Years (QUALY), as a general rule of thumb new interventions are recommended if the cost of one QUALY does not exceed £20,000. But a QUALY can only be assessed against the benchmark of the previous standard drug/service i.e there is a presumption that this is reliably known. However NICE has operated without this data, as such its recommendations on mental health and in particular on depression and the anxiety disorders are blind. Yet organisations such as IAPT (Improving Access to Psychological Therapies) establish their legitimacy to paymasters (NHS England and Clinical Commissioning Groups) by claiming the NICE seal of approval. NHS England and CCG’s prefer to nod to this ‘seal’ rather to enquire about IAPT’s claims, much less to set up an independent body to address the veracity of claims. This is not too surprising as there is a semi-permeable membrane between the Department of Health and service providers. Conflicts of interest have not been addressed.
Determining a QUALY with regards to mental health is not easy, but one QUALY could reasonably be interpreted as the cost of achieving the absence of meeting diagnostic criteria for a recognised psychiatric disorder for a year for a client, following say an IAPT intervention, this would be compared with the typical cost of achieving this goal with the same type of client in pre IAPT services. But no follow up of IAPT clients has been conducted that independently tracks diagnostic status. NICE is saying more than it knows, but at whose behest?
Dr Mike Scott