Without IAPT, The Same ‘50%’ Recovery Rate – Why Do CCG’s Fund It?

One of IAPT’s criteria for claiming patient recovery is shifting a patient’s PHQ9 score to less than 10. But in a study by Gilbody et al (2015) [ see link below] involving 179 patients undergoing treatment as usual in primary care with an initial diagnoses of depression and PHQ9 scores of above 10, 101, (56%) of patients recovered within 4 months. [ A study of treatment as usual cases by Moore at al (2012) similarly showed a 47% recovery].  IAPT currently claims a 50% recovery rate, the burden of proof is on IAPT to demonstrate that it produces results significantly different to those treatments engaged in before its’ inception.

Even when the metric is an adequate treatment response the differences between IAPT and treatment as usual (TAU) are not apparent. In the study  by Moore et al (2012) [see link below] of 576 TAU cases of depression who completed the PHQ9 twice (mostly within 3 months)  63% showed an adequate treatment response ( a drop of 5 or more points), this is not  discernibly different to IAPT’s findings.

CCG’s want it seems to be seen to be mindful of mental health, as their masters NHS England dictate, but don’t want to engage in effortful thinking in this domain, bypassing it by talking only of operational matters, numbers, waiting times etc.  It is a new political correctness that also permeates the political parties.

The true metric of recovery is returning a person to their usual self ( a minimum component of which is losing diagnostic status, assessed independently), IAPT has studiously avoided  such a hard outcome measure preferring its’ own surrogate. All this despite that the original randomised controlled trials for anxiety and depression insisting on hard outcome measures.

 

Unfortunately mental health charities are often now dependent on IAPT and private agencies seek to ape IAPTs metrics, the upshot is that for the past decade there has been precious little evidence based psychological treatment of the sort I advocated in Simply Effective CBT London: Routlege (2009).

https://www.dropbox.com/s/awwtpdhv0mxbtht/Treatment%20as%20usual%20recovery%20rate%202015%20Gilbody.pdf?dl=0

https://www.dropbox.com/s/mupj14fq14eba4g/Depression%2050%25%20natural%20recovery%20on%20PHQ9%20within%203%20months%20of%20GP%20diagnosis.pdf?dl=0

Dr Mike Scott

What If IAPT Had Never Happened?

Ten years on from the inception of the Improving Access to Psychological Therapies Service (IAPT), it is important to  review what would have happened but for IAPT. Using this comparison (what economists term the appropriate counterfactual), it is far from clear that IAPT has conferred any advantage and it is extremely doubtfuI whether the £1.3 billion spent on it has been worthwhile. Perhaps in the New Year IAPT should be renamed Impoverished Access to Psychological Therapies!

More about this anon.

 

Happy New Year

 

Dr Mike Scott

IAPT and Rudolph

Rudolph had a very shiny nose, in a routine consultation with  his GP, Dr Touchy-Feely, the latter said that it was medically unexplained and he could be referred/or refer himself to IAPT.

He replied that it was a long term physical condition and he didn’t think a psychological service was appropriate. The GP opined that he might have persistent somatic symptom disorder and entered this in his notes. . Later that day Rudolph had a telephone conversation with Father Christmas who wondered whether he could help him out that evening. Rudolph mentioned in passing his conversation with the  GP. Father Christmas observed that everyone knew he had a very shiny nose and could on occasion feel left out or ridiculed but was this really a psychological problem, didn’t IAPT have enough to do with all the anxious and depressed people! Rudolph replied sheepishly, perhaps I should ring IAPT in the New Year, after all the GP is saying I have got persistent somatic disorder. Father Christmas replied Dr Touchy-Feely, does not know what evidence based criteria are for anything and added whimsically ‘he doesn’t even believe in me’.

Have a great Christmas Folks

 

Dr Mike Scott

Involved In A Fatal Road Traffic Accident And IAPT Offers A Telephone Assessment

Paula (not her real name) was involved in a fatal road traffic in which her mother  died. Her GP referred her to IAPT, 6 months later she received a telephone call from them to arrange a telephone assessment.  She declined the telephone assessment, felt they were ticking boxes and was told it would be a further 2 month to wait for a face to face appointment.  So this is what is meant by IAPT care! When I saw Paula she was in tears throughout much of the session, had trauma related  guilt with regard to the rta and was suffering from depression and mild PTSD.  IAPT could do with the Christmas message of hospitality, but not just for Christmas.

May the peace and joy of Christmas be with you

 

Dr Mike Scott

Shambolic Mental Health Treatment for Children

An independent rigorous assessment of children’s mental health services is long overdue, wake up National Audit Office! Therapists are navigating children through a fog. Paula, not her real name, a 6 year old, had a traumatic incident at a fair and suffered separation anxiety  disorder. She had 6 treatment sessions with CAMHS, she was discharged on the basis of ‘low chance suffering from post traumatic stress’  and recalling the event with ‘no distress’.   But having seen her myself and assessing her using a standardised diagnostic interview she never did suffer from PTSD and the separation anxiety disorder has not been systematically addressed. Nevertheless the therapist calls for the whole family to attend ‘family systemic therapy’, notwithstanding that Dad does not live with them and sees mum as irresponsible for taking her to the fair. Mum sees this as just a further example of his being a ****** and is unphased by this!

The current zeitgeist is to ask for more resources for children’s mental health, putting mental health workers in school etc.  The idea is that adult mental health problems could be prevented by such actions but the evidence base on this is at present weak. But even in the unlikely event of extra resources being delivered,(as opposed to promised), if we multiply very poor treatment you still get very poor treatment.  It is crucially important to clarify the landmarks that child and adolescent therapists should use to assist children and their caregivers through the fog.

Charities often link up with formal bodies to provide services, but they are often a) desperate for funding and b) don’t have the training (or wish) to measure real world outcomes. Perhaps the best Christmas gift to children would be a truly independent and rigorous assessment of the psychological treatment they receive. This is not at all to marginalise the importance of support groups for children and adolescents with a wide range of problems.

Dr Mike Scott

IAPT Haemorrhaging Clients

The latest IAPT figures for August 2018 show 60.3% of clients attending attending less than 2 treatment sessions. Under the auspices of NHS England IAPT claims to offer NICE approved therapies for treating people with depression or anxiety but the typical recommended dosage of such therapies is 10 or more sessions! Casualties are strewn in ‘no-mans land’. The National Audit Office (NAO) rather than publish the results of its’ investigation has chosen to look the other way. Yesterday the NAO was very vocal on another Government Quango, Motability but mental disability appears not to be as deserving of critique as services for those with a physical disability. If 60% of physically disabled people were not enabled to get the vehicle they require, there would rightly be an outcry, yet the majority of IAPT referrals are expected to suffer in silence. The IAPT figures can accessed using the link below:

https://www.dropbox.com/s/crucmhktn3r88ud/IAPT%20Figures%20for%20August%202018.pdf?dl=0

Notwithstanding this IAPT in its’ pilot projects is expanding ‘IAPT care’ into the medically unexplained symptoms (MUS) field (see link below). Despite the concept of MUS being jettisoned from DSM-5 [American Psychiatric Association (2013)] –  in a radical departure from its’ predecessor DSM IV it cautions that it cannot be assumed that just because no physical explanation is proferred the problem must be psychological. Nevertheless IAPT in its report on integrated services comes up with an ‘MUS recovery rate’!

https://www.dropbox.com/s/f1taewasjrg4pyw/IAPT%20MUS%20Aug%202018.pdf?dl=0

Dr Mike scott

Telling It As It Is at IAPT

There is an urgent need for an independent investigation of IAPT. In an earlier blog ‘IAPT half baked’, an IAPT worker commented that it would be ‘hair raising’ for people to learn of his/her experiences. This past week I’ve come across 2 cases that exemplify this,

  1. ‘X’  was given 3 sessions of guided self-help therapy, judged ‘resistant’, treatment was judged unsuccesful on the basis of PHQ 9 and GAD7 results and it was recommended that ‘X’ was stepped up to trauma focussed therapy. But without any specification of what the trauma was or its’ sequelae.  Some months later ‘X’ began a series of 10+ sessions at step 3 for Generalised Anxiety Disorder (GAD) , but during treatment the therapist discovered ‘X’ experienced  a very distressing incident many years ago and was upset when thinking about it. This event became the treatment focus and by the end of therapy ‘X’ was allegedly less distressed by this incident. Treatment was judged successful on the basis of changes on PHQ9 and GAD7 scores, but the therapist discharge letter said ‘ may now need to be re-referred for treatment of GAD!
  2. ‘Y’ saw his/her GP immediately following a needlestick injury was given the IAPT telephone number and a telephone consultation took place within days, PHQ9 and GAD7 scales were completed and the scores were elevated and ‘y’ was scheduled for a face to face treatment 6 weeks later. If you were not distressed/anxious after a needlestick injury you really would be weird, does the GP and IAPT have to collude in this medicalisation of normal distress, is this really a proper use of resources? from a GP’s point of view I can see that it ‘off loads’ a case for a time but really!

My fear is that no one in power really wants to know what is going on at the coal face, it is not helped by the National Audit Offices failure to publish the results of its investigation into IAPT. One can only speculate that the champion’s of IAPT, NHS England have had a gentle word with the Office.  The effect is that a political correctness rules expressing concern about mental health, stigma and the need for more resources, but without getting close to the people effected and really listening to what is going on.

 

 

Dr Mike Scott

Antidepressant Usage Challenges CBT Treatment

CBT clients often wish to discuss discontinuation of their antidepressants or take precipitous action to do so. But CBT training rarely addresses such issues. The matter has been  given an extra urgency by a recent paper by James Davies and John Read which found that that half of antidepressant users have significant side effects when they attempt withdrawal., see link

https://www.dropbox.com/s/rs6x0hapwduccgz/antidepressants%20Davies-Read%202018.pdf?dl=0

But these withdrawal symptoms can be labelled as a return of anxiety/depression, a misdiagnosis and the GP then increases the dosage or switches the person to another antidepressant. Clients often then complain of being ‘zonked out’ and an increase in symptoms particularly impaired concentration, making CBT more difficult. The danger is that the CBT therapist can feel that they are on uncertain ground, marginalise the client’s medication concerns and hurriedly revert to whatever protocol was being followed. Unfortunately the therapist and GP are most likely located in different laces with no opportunity to chat about such matters.

The NICE guidelines for GPs states that withdrawal symptoms for antidepressants last a week or two after gradual withdrawal. but this advice was based on studies where patients had been on antidepressants for just 8-12 weeks.  Davies and Read point out that over half of those on antidepressants have been taking them for more than 2 years and suggest that this is a very different ball game, with withdrawal symptoms beginning some time after discontinuation. They call for more real world studies of the discontinuation of long term antidepressants.

In the light of the Davies and Read paper NICE is reconsidering its guidance to GPs.

 

Dr Mike Scott

Clinical Commissioning Groups Not Listening To GP’s on IAPT – The Chaos of Liverpool

Earlier this month Pulse reported ‘In Liverpool, Dr Barnett (GP) says services last year ‘couldn’t have been much worse’ and ‘GPs did not bother to refer patients [to IAPT] because nothing would happen’. Yet the Liverpool Clinical Commisioning Group in its report ‘Talk Liverpool Contract’ dated July 10th 2018 talked of a steady improvement of IAPT’s performance such that it fell just short of the target 50% recovery rate!  Via my MP Maria Eagle I complained that my own independent study of 90 former IAPT clients showed an overall 9.2% recovery rate. https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

The Chief Operating Officer,  for Liverpool CCG, Mr Ian Davies replied simply re-iterating IAPT’s national claims.

It is clear that when CCGs talk to IAPT Managers the discussion is about operational matters e.g number of client’s seen, waiting times etc and never about whether the Service makes a real world difference to patient’s lives. CCG’s have blindly taken on board IAPT’s own metric of recovery and its’ assessment of meeting targets, there would never be such incredulity about a drug. NHS Foundation Trusts ought to be challenging this naivety.

Dr Mike Scott

Unannounced Visits To IAPT Reveal……..

The Care Quality Commission (CQC) pay unannounced visits to establishments for vulnerable people and have thereby revealed tragedies such as Winterbourne View in 2011.  But the clients of IAPT are no less vulnerable, yet there is no inspection on their behalf.  I wonder what the CQC would make of a lady on the autistic spectrum accepted into IAPT for management of her anxiety,  catered for by a high intensity therapist who is allowed only 6 sessions, with no knowledge of autism or of the grey are between OCD rituals and aspects of autism.  The CQC would surely cry foul, but this is not an isolated example.

If IAPT practitioners are to be based in GP practices they could fall within the CQC’s orbit of ‘people with poor mental health’.  Had they visited the establishment where   the would be Bake Off winner,          Kim-Joy https://www.theguardian.com/tv-and-radio/2018/nov/12/i-was-preety-much-mute-at-school-the-bake-offs-kim-joy  worked they would have heard her tell, that she has a Master’s in psychology, she could provide only up to 6 half hour sessions in low intensity and was heading off to other pastures.  If they needed an independent window on what is going on in IAPT I would have given them the following comments from amongst the 90 clients that I saw:

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

There are valuable TV programmes such as ‘GPs Behind Closed Doors’, I wonder what the public would make of ‘;IAPT Behind Closed Doors’ but such a programme would have to escape censorship by NHS England (and IAPT leadership)  something GPs would not tolerate.

Dr Mike Scott