Only The Client Knows Whether Psychological Treatment Has Made a Clinically Relevant Difference

trouble is nobody asks them! When was the last time you remember a client being asked ‘are you back to your usual self with the treatment you have had’? Organisations, such as IAPT have their own metric, a decrease on a psychometric test and in secondary care psychiatrists will opine ‘seems a bit brighter to day, increase…’. These ‘metrics’ ensure the survival of the Organisation, but have no demonstrated relationship to loss of diagnostic status as assessed by a clinician independent of the service provider.

In a study by Stegenga et al (2012) see link below depressed patients were followed up over 3 years whether there depression took a chronic (17%), fluctuating (40%) or remitting course (43%) course they all showed decreases in PHQ9 scores throughout the study and without any psychological intervention. The only exception was a worsening of PHQ9 score at 6 months for the chronic subgroup. Similarly a 12 year study of anxious patients Bruce et al (2005) showed they were only suffering from their anxiety disorder 80% of the time. Thus finding a decreased psychometric test score per se does not mean anything.

Bruce et al (2005) linkhttps://www.dropbox.com/s/9powmto8miw60a2/Natural%20recovery%20in%20Social%20Phobia%20Panic%20Disporder%20and%20Generalised%20Anxiety%20Disorder.pdf?dl=0

Stegenga et al (2012) linkhttps://www.dropbox.com/s/k0x2fm0ds01no0k/natural%20course%20of%20depression%20stegenga%202012.pdf?dl=0

Organisations and Clinical Commissioning Groups much prefer to talk about operational matters, numbers and waiting lists and show no interest or expertise in reliably assessing clinically relevant outcomes. But it is not just these bodies, the leading journals have for the past decade predominantly published papers on the efficacy of psychological interventions with no insistence that there should have been blind independent assessment. Instead self-report measures have ruled with little awareness that their completion is subject to demand effects and the measures often bear no obvious relationship to the construct under examination.

It is difficult to escape the conclusion that clients are largely fodder for the Organisations. A problem that will not be resolved by increased funding for mental health services albeit that this is clearly needed or by atypical clients as tokens on mental health bodies. The fundamental problem is a lack of respect/reverence for clients.

Dr Mike Scott

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