The Improving Access to Psychological Therapies (IAPT) Service Fails To Make the Case for Its’ High Intensity Therapy



IAPT claims a 50% recovery rate when comparing Service entry and exit scores. It does so without any differentiation between treatment modality: low intensity CBT, high intensity CBT or the combination. However, a study from Northern Ireland focussing solely on the effectiveness of low intensity CBT also claims a recovery rate of 50% [Full paper reproduced below] using just Psychological Wellbeing Practitioners (PWPs). This must raise doubts about whether there is any added value to high intensity CBT. Alternatively IAPT’s way of assessing service effectiveness is seriously flawed. 


A New Mental Health Service Model for NI: Evaluating the Effectiveness of Low Intensity CBT (LI-CBT) delivered in primary/community care settings

Policy Briefing 8th March 2017

Dr Karen Kirby, Orla McDevitt-Petrovic (MSc), Dr Orla McBride, Prof Mark Shevlin, Dr Donal McAteer, Dr Colin, Gorman, Dr Jamie Murphy (Ulster University).

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The prevalence of mental health problems in Northern Ireland (NI) is 19%, and this is 25% higher than in England (DHSSPS, 2014). In recent years, there have been extensive consultations, and subsequent recommendations made in NI, in an effort to address this issue and to support an improved infrastructure for the training and development of those working within mental health services (DHSSPS, 2012, 2015). Reform within mental health services in NI has been informed over the past decade by the Bamford review from which two action plans have been proposed (DHSSPS, 2012, 2015). In response to this, researchers at Ulster University wanted to demonstrate an evidence base for the implementation of a new primary care/community based psychological therapies service model in NI, based on the UK ‘Improving Access to Psychological Therapies’ (IAPT) service model. This was informed by the National Institute of Clinical Excellence (NICE) guidelines, which advocates the use of low intensity cognitive behavioural therapy (LI-CBT) for mild to moderate anxiety and depression (NICE 2004a, 2004b). Evidence from IAPT sites suggest that the model is clinically effective (Clark, Layard, Smithies, Richards, Suckling & Wright, 2009) but that the appropriate resourcing of steps one and two is a more cost effective way to manage the high demands placed on health services. Hence, the current study aims to evaluate the effectiveness of implementing an IAPT service model using LI-CBT in primary and community care settings in NI. Two clinically valid routine outcome measures were used, which evaluate every client in every session, with data collection for the first phase of the study taking place between January 2015 and October 2016. Preliminary reliable change outcomes for the pilot cohorts showed recovery rates of 47.9%, improvement rates of 76.7% and deterioration rates of 6%. These findings indicate that the IAPT service model is clinically effective in a NI population. Data collection for the study is continuing between November 2016 and November 2017, using the same outcome measures, and additional follow-up data will also be examined in order to determine if the psychological benefits of interventions are maintained over time. Future analyses will also aim to identify individual and service level factors which potentially impact the effectiveness of the intervention.


The English IAPT initiative

‘Improving Access to Psychological Therapies’ (IAPT) is a large scale initiative which has received substantial government investment in England (Gyani, Shafran, Layard and Clark (2013). It was first implemented in 2007, and aims to improve access to evidenced-based psychological treatments for common mental health difficulties, primarily depression and anxiety (Clark, et al, 2009). ‘Access’ specifically refers to the provision of treatments which embrace utilization, and availability, as well as efficiency and effectiveness. Furthermore, improved access is attributed to equity and to promote a culture of social inclusion and patient centeredness (Gulliford, Hughes & Figeroa-Munoz, 2001).

The IAPT service model is informed by the National Institute of Clinical Excellence (NICE) guidelines, which advocate the use of cognitive behavioural therapy (CBT) in the treatment of anxiety and depression (NICE 2004a, 2004b). Importantly, these guidelines also recommend that psychological interventions are delivered according to a stepped care framework, whereby the most effective, yet least resource-intensive, treatment is delivered first. NICE guidelines recommend that mild to moderate depression and anxiety can be managed effectively using low intensity interventions within primary care and community level settings (DHSSPS, 2005). Low intensity in this case refers to forms of CBT treatment which can be delivered in non-traditional formats (e.g. via telephone/online) and often require less practitioner support in terms of the frequency and duration of sessions. The IAPT workforce delivering these interventions are referred to as psychological wellbeing practitioners (PWP: Richards and Whyte, 2011).

Evidence from UK IAPT sites suggest that low intensity CBT is an effective treatment for mild to moderate depression and anxiety (Clark et al, 2009). Gyani, et al. (2013) examined data from 32 IAPT sites, representing approximately 19,000 clinical cases, and reported that 40% of individuals had reliably recovered and 64% had reliably improved since using the service. Within IAPT services, clients complete the PHQ-9 (measuring depression), and the GAD-7 (measuring anxiety) at each contact. Improvement is determined using a reliable change index whereby six and four indicate reliable change in depression and anxiety respectively. Recovery requires a demonstration of reliable improvement, with final scores below clinical thresholds, on both psychometric measures at the end of treatment.

The IAPT initiative has also been demonstrated to have important cost benefits. The estimated average cost for a low intensity session and course of treatment was £99 and £493 respectively. These estimates are supportive of the originally proposed IAPT programme on cost-benefit grounds (Layard, Clark, Knapp & Mayraz, 2007;


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Radhakrishnan, Hammond, Jones, Watson, McMillan-Shields, & Lafortune, 2013). The rationale for nationwide implementation has also been motivated by the potential economic gains associated with increased productivity and re-employment (Layard et al., 2007)

Mental Health Services in Northern Ireland

The prevalence of mental health problems in Northern Ireland (NI) is 19%, and this is 25% higher than in England (DHSSPS, 2014). Despite the prevalence of mental health difficulties in NI being 25% higher, services in England spend more than double the per capita spend on the provision of support for individuals with mental health difficulties (DHSSPS, 2010; DHSSPS, 2014). In recent years numerous policy documents relating to mental health services in Northern Ireland have been published to address this issue and to support an improved infrastructure for the training and development of those working in mental health services (e.g. Making Life Better 2012-2023, Northern Ireland Public Health Framework 2012; Transforming Your Care, DOH 2011; Health and Wellbeing 2026, DOH 2016). Moreover, reform of mental health services in Northern Ireland has been informed throughout the past decade by the Bamford Review (Bamford, 2006). In 2016, the Department of Health Northern Ireland initiated an evaluation of the 2009-2011 and 2012-2015 Bamford action plans (DHSSPS, 2012, 2015). Preliminary findings highlighted that there remains a need to further promote psychological therapies, to improve access to services in times of crisis, and to improve involvement at the community and voluntary level. Funding reductions are considered to account, in part, for the failure to fully implement Bamford recommendations and best practice initiatives throughout the province. (DHSSPS, 2012, 2015).

The Strategy for the development and implementation of psychological therapy services in Northern Ireland (DHSSPS, 2010) recommended that psychological therapies should be a “core component” within mental health services (pg 49). Recommendations made in regards to strategy implementation indicate that additional investment, in the region of £4.4 million, would be required annually from 2011 within psychological therapies in order to facilitate significant reform.

However, the Bamford Vision acknowledged that further funding would be required for mental health and learning disability services across a 10 to 15-year period, due to historically inadequate investments and the growing need for psychological treatment in NI. Recently reported figures indicate that none of Northern Ireland’s five Health Trusts have met the 13 week waiting time targets for treating individuals with mental health problems during the last three years, and local government already acknowledged the need for a workforce strategy to avoid potential shortfalls such as this (HSCB, 2015). From the perspective of service users and providers, a recent report from Action Mental Health indicated that service users feel they are not treated like people but as problems to be managed. From a systemic perspective, serious concerns were highlighted regarding inadequate funding, fragmentation of services, poor communication and lack of leadership (AMH, 2015).

Overuse of pharmacological interventions

It has been recently reported that that GPs in Northern Ireland prescribe anti-depressant medications at a rate 2.5 times higher than in England and Wales (McClure, 2013). Whilst not disregarding the legacy of the ‘Troubles’, prescription rates were found to be significantly higher than in other UK regions with similar economic profiles and even higher rates of depression, which again points to an issue of potentially inadequate access to non- pharmacological help. In response, and in order to provide GPs with an alternative to medications for common mental health problems, ‘Primary Care talking therapy hubs’ were introduced in NI (HSCB, 2015). The aim of such Hubs is to advocate prevention and early intervention using services including counselling, CBT, group therapy, guided self-help, life coaching and signposting to community services. Hubs in the five Health and Social Care Trusts across the province are still in the process of being established, and there has been recognition from local government that additional hubs with appropriately trained staff are required (HSCB, 2015).

Psychological Therapies in Primary Care

Although the efficacy of early interventions such as low intensity cognitive behavioural therapy (LI-CBT) is most strongly evidenced with depression and anxiety, and although such approaches are shown to save money in the long term (Layard et al., 2007), a stepped care model has not yet been fully established in NI (Blane, Williams, Morrison, Wilson and Mercer, 2014). Psychological therapy service provision in NI has tended to focus on the more complex end of the spectrum of mental health difficulties, and consequently, educational and professional training has similarly concentrated largely on individuals working at these levels. In 2013, the Northern Ireland Mental Health Services Threshold Criteria acknowledged that low intensity therapists working at stepped care


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levels one and two, including those delivering LI-CBT, are crucial for the establishment of an effective stepped care approach to psychological therapy provision in the province (MHSTC, 2013).

Training of Psychological Wellbeing Practitioners in Northern Ireland

In light of the mental health problems faced by large numbers of the population in NI, and in recognition of the need for an appropriately skilled and experienced workforce to fill the aforementioned gap in service provision, Ulster University developed accredited training in evidence-based low intensity interventions for common mental health difficulties. Since 2014, this has facilitated the training of British Psychological Society accredited Psychological Wellbeing Practitioners (PWPs), who deliver low intensity cognitive behavioural therapy interventions to individuals within Primary/Community Care level services throughout training.

Aims and Objectives

Considering the evidence presented above, it is clear that the current provision of psychological therapies at the Primary/Community Care Level in NI is in its early stages of development, with few empirical evaluations to date of the effectiveness of treatment approaches at this level. Indeed, the recent DoH (2016) indicated that the improvement of access to psychological services has been wholly inadequate and significant funding is required to match that which is being offered in England. Hence, there is a need to provide evidence of a service model that works, and can be implemented effectively in NI. The main objective of the current pilot study is to present the preliminary findings of an evaluation of PWPs providing LI-CBT for common mental health difficulties working directly with the newly established ‘Primary care Talking Therapies Hubs’ and community care settings in an NI context. It was predicted that following a course of LI-CBT there would be a reduction in PHQ-9 and GAD-7 scores to normal range below clinical thresholds, and that these findings would be in keeping with existing IAPT UK outcomes, thereby providing initial evidence that the IAPT service model is effective in a Northern Ireland context.


This was a prospective study following a cohort of participants from baseline (before commencement of therapy), through the course of LI-CBT weekly treatment (1-11) sessions, and ‘follow-up’ (4 months post-discharge). This study is limited to examining changes in psychological status in participants before and after therapy; the follow- up analysis is part of an on-going project.


Trainee PWPs consisted of students on the MSc applied psychology course at Ulster University, which facilitated clinical skills, training, placements and supervision. Data from a total of 199 patients who attended a trainee PWP within the 2015 and 2016 cohorts was collected. (see figure 1). In keeping with IAPT recommendations (Gyani et al., 2013), the clinical outcomes reported here are related only to clients meeting “caseness” criteria. This required at least two contacts with a PWP as pre and post treatment scores cannot be collected based on a single initial session. A ‘case’ client must also have scored above the clinical thresholds on at least one of the measures at assessment, more specifically this refers to scores of 10 and/or 7 or above on the PHQ-9 and GAD-7 respectively. 165 clients were identified as “case” and 35 were identified as “non-case” prior to analysis, in accordance with this IAPT “caseness” criteria. Of the clients fitting caseness criteria, there were 105 females and 60 males. Ages ranged from 18 to 77, with a mean age of 39. 55% of patients were treated in community settings, 18% in a GP practice, and 27% at primary care services psychological therapies within a Northern Ireland NHS Trust.


As per IAPT service protocol, each client at each contact completed two routine outcome measures.

The Patient Health Questionnaire (PHQ-9) was used to measure the severity of depressive symptoms. This is a nine-item standardised measure which has been validated in a UK depressed population (Cameron, Crawford, Lawton & Reid, 2008). The scores range from 0 to 27, with a score of ten or more being the threshold to identify clinically relevant depressive symptoms (Kroneke, Spitzer & Williams, 2001).

The General Anxiety Disorder Questionnaire (GAD-7) has also been determined to have good psychometric properties having been validated in U.S. populations. The scores range from 0 to 21 and a score of eight or more


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being the threshold to identify clinically relevant general anxiety disorder (Kroneke, Spitzer, Williams, Monahan & Lowe, 2007).

Trainee PWPs consisted of students on the MSc applied psychology course at Ulster University, which facilitated clinical skills, training, placements and supervision. Data from a total of 199 patients who attended a trainee PWP within the 2015 and 2016 cohorts was collected. In keeping with IAPT recommendations (Gyani et al., 2013), the clinical outcomes reported here are related only to clients meeting “caseness” criteria. This required at least two contacts with a PWP as pre and post treatment scores cannot be collected based on a single initial session.

A ‘case’ client must also have scored above the clinical thresholds on at least one of the measures at assessment; more specifically, this refers to scores of 10 or above on the PHQ-9 and/or 8 or above on the GAD-7. 165 clients were identified as “case” and 34 were identified as “non-case” prior to analysis, in accordance with the IAPT “caseness” criteria. Of the clients fitting caseness criteria, there were 105 females and 60 males. Ages ranged from 18 to 77, with a mean age of 39. 55% of patients were treated in community settings, 18% in a GP practice, and 27% at primary care psychological therapies service within a Northern Ireland NHS Trust.

Reliable change rates

The Reliable Change Index (Jacobson & Truax, 1991) is an appropriate way of assessing deterioration or improvement in anxiety and depression symptoms, as it allows one to determine whether an increase or decrease in psychometric scores from baseline to post-treatment exceeds the measurement error of the relevant scale, and thereby can be considered statistically reliable. In keeping with existing IAPT evaluations (Gyani et al., 2013), a reduction or increase of six or more points on the PHQ-9 and a reduction or increase of four or more points on the GAD-7 have been determined as the thresholds for reliable change in depression and anxiety symptoms respectively. Clients are considered to have ‘reliably improved’ if either of their measure scores reliably decreased and the score for the other measure either remained the same or did not reliably deteriorate. Clients are considered to have ‘reliably deteriorated’ if either measure score reliably increased, or the other score either also increased or did not reliably improve. A reliable recovery index was also used in line with existing IAPT studies (Gyani et al., 2013). Clients are considered to be ‘reliably recovered’ if they scored above the clinical threshold on at least one psychometric measure at assessment interview, showed reliable improvement during the course of treatment, and scored below clinical thresholds on both the PHQ-9 and GAD-7 at the point of treatment completion. For example:

  •   A case client with the following scores would have demonstrated reliable improvement: baseline PHQ-9 (13), baseline GAD-7 (9), final PHQ-9 (7), final GAD-7 (8).

  •   A case client with the following scores would have demonstrated reliable deterioration: baseline PHQ-9 (14), baseline GAD-7 (10), final PHQ-9 (9), final GAD-7 (14).

  •   A case client with the following scores would have demonstrated reliable recovery: baseline PHQ-9 (15), baseline GAD-7 (8), final PHQ-9 (8), final GAD-7 (5)


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A total of 199 participants sought access to the service. Of these, 198 were assessed and of these 178 attended a second session at least; the rate of uptake of LICBT was therefore 89.4%. Overall, 47.9% of patients who met caseness criteria demonstrated reliable recovery. 76.7% of these patients demonstrated reliable improvement, and 6.1% demonstrated reliable deterioration (see table 1).

Table 1: Frequencies and percentages of reliable recovery, improvement and deterioration rates for LICBT patients meeting caseness criteria for cohorts 2014/15 and 2015/16.


*Caseness criteria met (n= 165)

page6image14839424 page6image14839616 page6image14839808 page6image17089632 page6image17093664

No Missing

Reliable Improvement demonstrated

125 (77%) 38 (23%) 2 (1.2%)

Reliable Deterioration demonstrated

10 (6%) 153 (94%) 2 (1.2%)

Reliable Recovery demonstrated

78 (48%) 85 (52%) 2 (1.2%)


*At least 2 sessions attended and above clinical thresholds on one or both measures at baseline = caseness


Initial Northern Ireland outcomes: Clinical effectiveness

Findings from the current study are in keeping with outcomes from UK IAPT sites including the previously reported 2015/16 outcomes (HSC, 2016). More specifically, when NI reliable change rates are compared directly with the most recently published IAPT UK outcomes, recovery rates are 47.9% and 46.3% respectively. Improvement rates are 76.7% and 62.2% for NI and England respectively (HSC, 2016). These preliminary results provide initial evidence that low intensity cognitive behavioural therapy is an effective treatment for mild to moderate level mental health difficulties in NI. As reported earlier the prevalence of mental difficulties in NI is 25% higher than in England (DHSSPS, 2014). More explicitly, the Northern Ireland Health Survey (2014/15) reported that 19% of respondents exhibited symptoms of a potential mental health problem (Bell & Scarlett, 2015). Assuming this population was suitable for LI-CBT, it may be estimated based on the current findings that prevalence could be reduced to 4.4% with reference to improvement rates and 9.9% with reference to recovery rates.

Cost benefits: increasing reemployment and productivity

Furthermore, research also indicates that 22% of individuals in NI live in poverty (Bell & Scarlet, 2015). Indeed, in Northern Ireland, the prevalence of mental health difficulties is doubled (30%) for those in the most deprived areas, when compared with those in areas of less deprivation (15%) (Bell & Scarlett, 2015). It is estimated that recent public cuts have affected Northern Ireland in a particularly detrimental way, given that the region relies on public spending for 62.2% of its output, compared to 39.8% in the rest of the UK.

Compared with other regions of the UK, NI has the highest proportion of adults not in work (28.4%). More precisely, this is 5% higher than the UK average (O’Neill, McGregor & Merkur, 2012). Absenteeism is heavily attributed to mental health difficulties, more specifically accounting for 31.9% of all lost days, and 39.1% of long- term sick leave (NISRA, 2015). The economic gains directly associated with IAPT in England in the first three years include almost 45,000 individuals moving off benefits (Clark, 2011). As the IAPT model has been applied to mental health clients in the current study, the LI-CBT interventions used here could have a similar impact on individuals moving off benefits and returning to work in NI. The findings of the current study can therefore be


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tentatively applied to infer that such evidence based interventions for common mental health problems could reduce rates of absenteeism in the province. Using the NISRA figures, days lost through mental health issues could therefore be reduced to 7.43% as per improvement rates found in the current study, and 16.7% as per recovery rates. However, this would need to be formally evaluated, and hence our future research recommendations are to assess prospective employment/benefit rates for the 2016/2017 cohort.

Further expansion of the English IAPT initiative has been recommended as a step to achieving better access to mental health services by 2020 (DOH, 2014). Investment in health care is important for both socioeconomic and ethical reasons, but has also been emphasised in order to counteract perceived “institutional bias”. More resources are dedicated to physical healthcare even though mental ill health can accrue an annual societal cost of up to 100 billion (DOH, 2014).

Moreover, Layard and Clark (2015) have recently reported on reasons why more psychological therapy would cost nothing. In the majority of wealthy countries, approximately 1% of the working age population are on benefits due to depression or anxiety. This costs the UK government £650 more per month per person, compared with if they were not receiving these payments. If a minimum of just 4% of this patient population worked for just one more month following treatment, the actual cost of treatment would be fully repaid. The argument to expand service provision is therefore thoroughly justified.

Adhering to the evidence base: Delivering the right treatment, at the right time, in the right place

As outlined earlier, the IAPT service model is informed by evidence based clinical guidelines. Our findings support these NICE guidelines in a NI context, which advocate the use of cognitive behavioural therapy for depression and anxiety. NICE assemble a panel of experts made up of clinicians, researchers and consumers who carefully review the available evidence base on the optimum treatments for each physical and mental health problem. In 2004, NICE carried out systematic reviews of research investigating the effectiveness of interventions for depression and anxiety disorders. The resultant clinical guidelines advocate the provision of specific kinds of cognitive behavioural therapy (CBT) for depression and anxiety disorders (NICE, 2004). Crucially, cognitive behavioural therapy is considered to be more effective than medication given that it reduces the likelihood of relapse by at least 50%, and moreover, the vast majority of patients prefer it to a psychological treatment (McHugh, Whitton, Peckham, Welge and Otto, 2013).

As previously outlined, NICE guidelines further recommend that mild to moderate depression and anxiety can be managed effectively using low intensity interventions within primary care level settings (DSSPS, 2005). Furthermore, low intensity interventions improve the flexibility, capacity and responsiveness of the relevant services while increasing patient-choice, and enhancing service cost-effectiveness (Bennett-Levy et al., 2012).


Currently, the mental health service framework in NI does not formally apply this NICE evidence, which has also been highlighted in the recent Evaluation of the Bamford Action Plans (DoH, 2016). Our findings indicate that reliable recovery and improvement have been demonstrated for clients in NI who have presented with common mental health difficulties. Indeed, LI-CBT interventions (provided by PWPs) provides the only evidence base to date in NI for treating anxiety and depression at stepped care levels 1-3. Additionally, the Bamford evaluation highlighted a need to further promote psychological therapies, to improve access to services in times of crisis, and to improve involvement at the community and voluntary level (DOH, 2016; Betts &Thompson, 2017). Our initial findings indicate that PWP’s have addressed this need.


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Recommendations and plans for future low intensity CBT research in Northern Ireland

Clinical Policy Recommendations:

  •   Whilst the findings of this study are preliminary, the current pilot offers a potential solution to addressing the need for evidence-based treatment and suggests that low intensity CBT (provided by accredited PWPs), is a clinical and cost-effective intervention, as well as being an effective service model within primary and community care settings in NI (stepped care 1-3).

  •   Therefore, our recommendation to practice and policy implementation, is that in order to assist the people of NI to gain access to appropriate, clinical and cost effective psychological interventions at steps 1-3, a province-wide PWP service (embedded within the talking therapy hubs and GP practices) needs to be fully established and adequately funded. This could potentially prevent more complex mental health issues through the use of early intervention and quicker access to services with reduced waiting times, and by enabling service users to access the right treatment in the right place at the right time.

  •   Indeed, some recent recommendations made by Sands (2017) have suggested the placing of mental health practitioners, offering the appropriate level of CBT, in every GP practice in NI. We are suggesting that PWP’s can be that ‘mental health practitioner’, who are fit for purpose and fit for the future of NI mental health services.

    Research recommendations:

  •   The collection of patient data and routine outcome measures is continuing at pre-treatment, post treatment and follow up points. In this study future analyses will focus on this larger sample of all previous, current and future cohorts combined. Reliable recovery, improvement and deterioration rates will be produced.

  •   Previous IAPT studies have determined that many of the psychological benefits resulting from interventions had been maintained (Clark et al., 2009). In order to produce comparative data regarding longer-term effectiveness, future N. Ireland research will also examine data collected from clients at a four month follow-up point after discharge from the service.

  •   In order to test for individual differences in treatment effect, a series of latent growth curve models will be specified and tested in order to determine if there are different rates of change for unobservable sub- populations, and to identify individual or service level variables which potentially increase or reduce the effectiveness of the intervention.

  •   Furthermore, data on employment statuses and medication usage pre and post treatment will be scrutinised. Increasingly, governments are driven by the recognition of the huge economic and social costs of high prevalence disorders, and so we need future research to evaluate cost effectiveness in order to inform future service design and planning. Randomised controlled trials facilitating a comparison of service models may also provide further evidence for the effectiveness of the IAPT model in a Northern Ireland context.


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Betts, J and Thompson, J (2017). Mental Health in Northern Ireland: Overview, Strategies, Policies, Care Pathways, CAMHS and Barriers to Accessing Services. Research and Information Service Research Paper. Northern Ireland Assembly.

Blane, D. N., Williams, C., Morrison, J., Wilson, A., & Mercer, S. (2014). Psychological therapies in primary care: a progress report.

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The Damaging Consequences of Not Offering The Best Mental Health Treatment Initially

many will vote with their feet when it comes to further treatment from the same source. Stepped care is the treatment model adopted by the UK Government’s Improving Access to Psychological Therapies (IAPT) Programme. A third (34%) of those who have low intensity therapy are stepped up to high intensity city, according to the IAPT Manual 2021, but the Manual cautions there is considerable local variation in this figure. The question is why? This does not sound like clients following well-defined pathways. As far as I can ascertain IAPT does not publish a recovery rate from low intensity alone, so it is not known what proportion haemorrhage from low intensity.  IAPT is the only show in Town for most people so it is not surprising that when treatment fails some return. For every 2 people referred to IAPT 1 person is attending for between their second and tenth plus courses of treatment – a revolving door. [Following a Freedom of Information Request from Dr Elisabeth Cotton in 2018, it appears that 1.5 million people were referred to IAPT between 2 and 10 or more occasions in a 6 year period (2012-2018), with 3.2 million people referred just once].



What is going on here? NHS England is replete with the following luminaries according to the IAPT Manual (2021), so it is no surprise that there has been no publicly funded independent audit of the Service:

Current NHS England team

Sarah Holloway, Head of Mental Health, NHS England
Xanthe Townend, Programme Lead – IAPT & Dementia, NHS England

David M. Clark, Professor and Chair of Experimental Psychology, University of Oxford; National Clinical and Informatics Adviser for IAPT

Adrian Whittington, National Lead for Psychological Professions, NHSE/I and HEE; IAPT National Clinical Advisor: Education

Jullie Tran Graham, Senior IAPT Programme Manager
Hayley Matthews, IAPT Programme Manager, NHS England Andrew Armitage, IAPT Senior Project Manager, NHS England Sarah Wood, IAPT Project Manager, NHS England

 It appears common sense for IAPT to offer the least costly service first e.g computer assisted therapy and then progress clients to the more costly face to face service if the minimalist intervention has not worked. But IAPT have borrowed from medical care a modus operandi that is not fit for purpose in mental health. For example there is evidence that for some with back pain, physiotherapy will resolve  problems and is the sensible first line treatment, with progression to the costly surgical interventions if physiotherapy does not suffice. But low intensity psychological therapy does not have the evidence base of physiotherapy. This opens up the likelihood that LI will fail to return the client to their best functioning.  Approx a third of clients (37%) receive low intensity only and a third (29%) high intensity only.


The mental health clients take on a failed  first line treatment is likely to involve personalisation e.g  ‘I am stupid, couldn’t quite get what was being asked to do’ and arbitrary inferences e.g ‘I shouldn’t have expected anything would work with me, just my luck’. This is quite different to how most people would likely respond to a failed first line physical intervention. For mental health treatment it may be the the best treatment should be provided first. At a minimum clients should be informed that they are consenting to what is known to be second best.


Dr Mike Scott


Decrypting the Improving Access to Psychological Therapies (IAPT) Code

IAPT communications have an agenda, their focus is on persuading their source of revenue, local Clinical Commissioning Groups (CCGs) to expand funding, to cover staffing costs of £0.5billion by 2024.  To achieve this goal it uses language that is familiar to the GPs that comprise CCGs, ‘NICE compliant’, ‘recovery’ and claiming a comparability of outcome to those in randomised controlled trials. But CCG’s are themselves under orders from NHS England, who have never critically appraised IAPT’s claims.

The secret to breaking the IAPT Code, is strangely its’ use of the ICD-10 code (the World Health Organisation’s labelling system for all disorders). The recent IAPT Manual (August 2021) recommends that IAPT clinicians give at least one code to each client, to characterise their debility. But nowhere in the Manual does it suggest that IAPT clinicians make a diagnosis. An ICD-10 code is only as reliable as the diagnosis made. The Manual claims that NICE Guidelines are based on ICD-10 codes and that IAPT is therefore NICE compliant.  However the treatments recommended by NICE are all diagnosis specific, it follows that if there is no diagnosis there can be no fidelity to a NICE protocol. A key part of IAPT’s code is to gloss over that IAPT’s interventions are based, not on diagnosis but on ‘problem descriptors’. The silent assumptions are that:

a) there would be reliable agreement (reliability) between clinicians about what would constitute a clients main problem and

b) there is a body of evidence that a problem descriptor acts as a key to unlock the door to a specific protocol. Further that the specific protocol has been demonstrated to confer an added value, over and above an active placebo, for the chosen problem descriptor. There is an assumption of clinical utility.

But there is no empirical evidence for either a) the reliability or b) the clinical utility. 

IAPT operates its’ own coding device, akin to the Enigma machine used by the Germans in World War 2, and it has as a result ill-served millions. NHS England and CCG’s have totally failed to recognise its’ operation, believing instead IAPT’s public broadcasts e.g a 50% recovery rate, when independent assessment indicates a 10% recovery rate Scott (2018)

Dr Mike Scott

Improving Access to Psychological Therapists (IAPT) or Care Assistants?

The staffing costs of the Improving Access to Psychological Therapies (IAPT) Programme is set to rise to £0.5 billion per year, but the National Audit Office (NAO) has failed to determine whether it is value for money. The average Clinical Commissioning Group (CCG) will need to increase IAPT staffing by 60-75% to meet the 2024 NHS Access Target ,according to the updated IAPT Manual (August 2021). Currently the service employs 8000 staff, another 3,800-6,000 are ‘needed’, taking the total to between 11,800 and 14,000 in the next 3 years.  Assuming a staffing cost of £35K per employee per year and the employment of 13,000 IAPT therapists, annual staff costs will be £455 million a year i.e approximately £0.5 billion per year.  But the true cost will be even greater when overheads  such as rent, phone lines are included. Extrapolating backwards, over £5billion will have been spent on IAPT staff since its inception without independent audit and no intention of NAO audit.

But the pandemic has highlighted the shortage and poor pay of Care Assistants. Drew et al (2021) sampled IAPT therapist-client interactions and noted a steadfast refusal to let clients tell the story behind their distress. A member of the public listening to these exchanges might contrast them with those of a Care Assistant making visits to a terminally ill patient so they can die at home with their family. The public would I think see the Care Assistant’s work as being more valuable and puzzled that the IAPT worker is paid twice as much.

There is a move to have health and social care under one umbrella, perhaps the NAO might explain why there should not be better pay for the Care Assistants and an increase in numbers at the expense of expansion of IAPT services. I came across this advert for Care Assistants in my area:

a much better investment than Talk Liverpool with a 10% recovery rate, Scott (2018) ‘IAPT- The Need for Radical Reform’

Dr Mike Scott

The Improving Access to Psychological Therapies (IAPT) Programme and The British Psychological Society (BPS)


The BPS has enthusiastically supported IAPT from its’ inception in 2008.  Improving access to psychological therapies is clearly a laudable goal, as most people with a mental health problem are not offered psychological therapy. The Society has led the course accreditation process for IAPT’s, Psychological Wellbeing Practitioners (PWPs) low-intensity training since 2009. Features on individual PWP’s have featured periodically in the pages of The Psychologist. In 2009, The Psychologist published a letter from the then President of the British Association for Behavioural and Cognitive Therapies (BABCP) stating that BPS members on the IAPT Education and Training Project Group supported BABCP’s accreditation of high intensity training programmes and noted that there were BPS members on the Accreditation Oversight group.

But the enthusiasm of BPS to give away psychological therapy has not been matched by a concern, to listen to the concerns of service users. Specifically:

  1. At no point has BPS suggested that it is inappropriate for IAPT to mark its’ own homework. The latter’s reliance entirely on self-report measures completed often in the prescence of the IAPT therapist, should have had any self-respecting psychologist crying ‘foul’ and calling for independent assessment.
  2. A concern for service users, should have led BPS to insist that a primary outcome measure must be clearly intelligible to the client. But there has been no specification of what a change in X as opposed to a change of Y would mean to a client on the chosen yardsticks of the PHQ-9 and GAD-7.
  3. BPS has been strangely mute on the fact that two self-report measures have been pressed into service to validate IAPT’s approach, with no suggestion that such an approach needs to be complemented by independent clinician assessments that go beyond the confines of the 2 disorders (depression and generalised anxiety disorder) that the chosen measures address.
  4. If a drug company alone extolled the virtues of its’ psychotropic drug, BPS members would quite rightly cry ‘foul’ insisting on independent blind assessment using a standardised reliable diagnostic interview. But from the BPS there has been a deafening silence on the need for methodological rigour when evaluating psychological therapy. This reached its’ zenith In the latest issue of The Psychologist, September 2021, when the Chief Executive of an Artificial Intelligence Company, was allowed to extol the virtues of its’ collaboration with four IAPT services. No countervailing view was sought by The Psychologist, despite it being obvious that the supposed gains were all in operational matters e.g reduced time for assessment, with no evidence that the AI has made a clinically relevant difference to client’s lives.


In 2014 I raised these concerns in an article ‘IAPT – The Emperor Has No Clothes’ I submitted to the Editor of the Psychologist which was rejected and he wrote thus ‘I also think the topic of IAPT, at this time and in this form, is one that might struggle to truly engage and inform our large and diverse audience’. This response was breathtaking given that IAPT was/is the largest employer of psychologists.

Fast forward to 2018 and I wrote and had published in 2018 a paper ‘IAPT – The Need for Radical Reform’ published in the Journal of Health Psychology, presenting data that of 90 IAPT clients I assessed independently using a standardised diagnostic interview only 10% recovered in the sense that they lost their diagnostic status, this contrasts with IAPT’s claimed 50% recovery rate. The Editor of the Journal devoted a whole issue to the IAPT debate complete with rebuttals and rejoinders. But no mention of this at all in the pages of The Psychologist.

It appears that BPS operates with a confirmation bias and is unwilling to consider data that contradicts their chosen position. If psychologists cannot pick out the log in their own eye how can they pick out the splinter in others? In 2021 I wrote a rebuttal of an IAPT inspired paper that was published in the British Journal of Clinical Psychology, ‘Ensuring IAPT Does What It says On The Tin’, but again no mention of this debate in the Psychologist.

In my view the BPS is guilty of a total dereliction of duty to mental health service users in failing to facilitate a critique of IAPT. It has an unholy alliance with BABCP who are similarly guilty. Both organisations act in a totalitarian manner.

Dr Mike Scott

Notice Served On IAPT’s Claim

of a 50% recovery rate. The Editors of Lancet Psychiatry S2215-0366(21)00123-1 have challenged researchers to demonstrate that an acclaimed intervention makes a difference that service users would recognise. Thus making the consumer of mental health services centre stage rather than a change in score on a test. In addition researchers are asked to justify their primary outcome measure. In interpreting test results the Editors insist that  author’s must clarify what a change of X would mean to a service user as opposed to a change of Y. A recently published paper in the Journal, using IAPT data, S2215-0366(21)00083-3 would probably not have been published, if it had not been accepted just before the new guidance was implemented. If other Journal editors follow suit, IAPT’s wings will have been clipped over the claims of IAPT and its’ fellow travellers, such as the British Psychological Society (BPS) and the British Association of Behavioural and Cognitive Therapies (BABCP).  There has been a dereliction of duty by BPS and BABCP.


In this connection I have had the following correspondence with the Lancet Psychiatry  Editors:

My letter

When A Difference Makes No Difference

In June this year the Lancet published guidance [Boyce et al (2021)] for mental health researchers to ensure that the primary outcome measure employed in a study needs to be meaningful. Researchers were asked to a) justify their choice of an outcome measure and b) specify what a change of X or Y on a measure would mean for a service user. Contemporaneously, Lancet Psychiatry published a study by Barkham et al (2021) that made no attempt to address the Editor’s expressed concerns.

Barkham et al (2021) chose to adopt the Improving Access to Psychological Therapies (IAPT) primary outcome measures the PHQ-9 [Kroenke et al (2001)] and GAD-7 [Spitzer et al (2006)], without any discussion. There is no comment that these are self-report measures, subject to demand characteristics and that changes are impossible to interpret without comparison to an active placebo treatment.

The Barkham et al (2021) study involved comparison of person-centred counselling and cognitive behaviour therapy (cbt) in a high intensity therapy service delivered by IAPT. Curiously patients were screened for the study using the Clinician Interview Schedule Revised but neither this nor any standardised diagnostic interview was used as an outcome measure. Why such apparent blindness? The answer is apparent reading the declaration of conflicts of interest, the authors are either devotees of person-centred counselling or have links with IAPT. Their take home message is that person centred counselling might be better than CBT for depressed patients. But there is no attempt to address the question of what proportion of patients lost their diagnosis status and for how long, as determined by an independent blind clinical assessment using a standardised interview. Service-users interests are ill-served by this type of study which additionally ignored data that suggest the recovery rate in IAPT is just 10% [Scott (2018)].


Barkham, M., Saxon, D., Hardy, G. E., Bradburn, M., Galloway, D., Wickramasekera, N., Keetharuth, A. D., Bower, P., King, M., Elliott, R., Gabriel, L., Kellett, S., Shaw, S., Wilkinson, T., Connell, J., Harrison, P., Ardern, K., Bishop-Edwards, L., Ashley, K., Ohlsen, S., … Brazier, J. E. (2021). Person-centred experiential therapy versus cognitive behavioural therapy delivered in the English Improving Access to Psychological Therapies service for the treatment of moderate or severe depression (PRaCTICED): a pragmatic, randomised, non-inferiority trial. The lancet. Psychiatry, 8(6), 487–499.

Boyce, N., Graham, D., & Marsh, J. (2021). Choice of outcome measures in mental health research. The lancet. Psychiatry, 8(6), 455.

Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001;16: 606–13.

Scott M. J. (2018). Improving Access to Psychological Therapies (IAPT) – The Need for Radical Reform. Journal of health psychology, 23(9), 1136–1147.

Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006; 166: 1092–97.


August 13th 2021


Thank you for your letter to The Lancet Psychiatry. We are pleased to see that our initiative re primary outcome reporting has been noticed.  We are applying this now but did not apply it retrospectively to papers accepted before publication. The Barkham et al paper was published online on 14 May, six weeks after the Comment, but was accepted and edited before our new policy was in place. 

For Correspondence, our information for authors states: Letters written in response to previous content published in The Lancet Psychiatry must reach us within 4 weeks of publication of the original item.  We do extend this to after the original item has been published in an issue but I’m afraid that your letter is still outside the window for the Barkham et al paper, so we have decided not to publish it.

Although this decision has not been a positive one, I thank you for your interest in the journal.

Yours sincerely,

Joan Marsh

Joan Marsh MA PhD

Deputy Editor


Dr Mike Scott


No Reduction In the Prevalence of Mental Disorders Since IAPT

this is the conclusion of Australian researchers Why then have successive Uk Governments spent £billions on the Improving Access to Psychological Therapies (IAPT) since its’ inception 13 years ago? Given that there is no evidence that IAPT represents an added value over pre-existing IAPT services, its’ continued funding suggests vested interests hold sway. The National Audit Office (NAO) had concerns and began an investigation but stopped citing Brexit, Carillion etc. Further following a Freedom of Information request from myself I was informed that they have no intention to restart the investigation.

Curiously the Australian researchers accept at face value IAPT’s claim of a 50% recovery rate, but there has never been any publicly funded independent confirmation of this. IAPT has been left to mark its’ own homework. My own study as an independent Expert Witness to the Court, and using a standardised diagnostic interview suggested that the recovery rate is 10% [Journal of Health Psychology].

Dr Mike Scott

IAPT’s Rigidity – The Antithesis of Personalised Care


the mantra is ‘offer just 6 sessions, keep to the therapist’s original formulation of the client’s difficulties, don’t consider alternative hypotheses, even when circumstances change. If necessary offer another 6 sessions’. The case below exemplifies this:

A few years ago Mr X suffered an episode of depression, his GP referred him to the Improving Access to Psychological Therapies (IAPT)Programme were he underwent a telephone assessment. On the basis of the completed psychometric test, he was assigned to a 6 week Group CBT programme with about 12 people attending each session. He found the sessions helpful, in that he then gave less emphasis to work and engaged in more excercise.  However at a telephone follow up interview he relayed, that he had been involved in a terrible house fire, struggling to breathe when he escaped. Mr X was taken to Hospital and treated for smoke inhalation and minor burns. The therapist agreed that he should have a further 6 sessions but this time face to face. When I assessed him at the end of the individual CBT he was suffering a further episode of depression, had many of the symptoms of  PTSD but not the intrusions, was phobic about the possibility of fire and suffering from binge eating disorder. However the sequelae of the fire was not addressed at all in the IAPT treatment, when he tried to make these concerns a focus, they were dismissed and the therapist insisted on recapping what had been discussed in the group. He and his wife commented that this seemed totally inappropriate. (Some details changed to protect confidentiality).


Personalised medicine is nowhere to be seen.
The BABCP has its’ Annual Conference in September in Belfast, the place were the Titanic was built, I very much
doubt that they will consider the structural defects of IAPT anymore than the White Star Line were transparent
about the failings of their vessel.
But Mr X is the tip of the iceberg of those failed by IAPT. The Court of Inquiry into the sinking of the Titanic had
many vested interests. The IAPT prime movers have powerful connections and doubtless the same would happen if
ever there was an inquiry into IAPT, but at least it would be a start. For now IAPT steams forward at maximum speed,
with many employees wishing to jump ship, but no vessels nearby and having to contend with the familiar tunes
from Belfast.
Dr Mike Scott

Almost Half of Adults Struggling With Mental Health or Substance Abuse

according to a study conducted by the US Center for Disease Control (CDC) in June 2020. With 31% suffering anxiety/depression symptoms, 26% trauma/stressor-related disorder symptoms, 13% started or increased substance use and 11% seriously considered suicide. Doubtless there would be similar findings if such a study was conducted in the UK now. At face value we have a ‘mental health pandemic’.  But actually the figures are almost certainly an artefact of relying on self-report measures says Dr Pies writing in the Psychiatric Times in October 2020. In his article he points out that reliance was placed on a self-report measure the PHQ-4 and no diagnostic interviews were conducted. The article  link is

But in the UK the Improving Access to Psychological Therapies (IAPT) programme bases its treatment of common mental health disorders purely on self-report measures. In terms of its own modus operandi they have probably been unwittingly denying access to great swathes of people since the onset of the pandemic! It is noteworthy that they have not mounted a defence that they are too under resourced to even begin to see such large numbers of people, this may have bestowed some credibility. Arguably, it has become the Denial of Access to Psychological Therapies Programme (DAPT). IAPT cannot have it both ways either it has massively denied treatment throughout the pandemic/ failed to acknowledge a grave mental health crisis or its’ modus operandi is fundamentally flawed! Either way there is need for an independent public inquiry into IAPT. 

Dr Pies October 2020 Psychiatric Times 

Paranoid, But Judged Recovered If Your Conviction of Threat Falls Below 50%

this is the primary outcome measure used in a just published study of CBT for persecutory delusions But would the typical person suffering from schizophrenia recognise this metric? What if convictions take a variable course and are mood dependent? What is going on here? Unrestrained by such questions Freeman et al (2021) proclaim in their advertisement for the 5 day online course for the Programme:

‘it is the most effective psychological treatment for persecutory delusions. Half of patients have recovery in their persecutory delusion with the Feeling Safe Programme’

‘Recovery’ here has a meaning far removed from common parlance. ‘When I use a word,’ Humpty Dumpty said, in rather a scornful tone, ‘it means just what I choose it to mean – neither more nor less.’ —LEWIS CARROLL, Through the Looking-Glass, 1871. If my conviction about the likelihood of being flooded fell to less than 50%, I would still be wanting to relocate!

Allegiance Bias

Freeman et al (2021) are evaluating their own Feeling Safe Programme but no mention that therefore their study might be prone to allegiance bias. The same therapists administered the Feeling Safe Programme and the comparison Befriending Programme. Given that the therapists knew that the hypothesis was that the former would prove superior to the latter, they are likely to be more enthusiastic about the CBT. Twenty sessions were to be delivered in 6 months in each modality but in the event more sessions were delivered in the CBT. Thus the possibility of allegiance bias amongst the therapists cannot be ruled out. It is therefore not surprising that a statistically significant difference was found between the two arms of the study. But this does not necessarily demonstrate the added benefit of CBT – a further confounding factor is that  71% of those in befriending were on antidepressants compared to 50% in CBT.

Replication Crisis

Freeman et al (2021) make the common cry of all researchers for more research, but there is no mention of the need for independent replication. This latter is particularly important as previous studies have not demonstrated the added value of CBT for persecutory delusions.

Inappropriate Outcome Measure

Clients in CBT were encouraged to take a 6 session module ( the Feeling Safe Module) targetting threat beliefs, how can the latter then be a credible outcome measure? Broader measures such as functioning as I was before I became paranoid or even as I was when I was least paranoid would have been more credible primary outcome measures.  Further the secondary outcome measures used were all based on self-report measures, there was no standardised diagnostic interview conducted. Whilst diagnostic labels were affixed at entry into the study ( on what basis is not clear), they were ignored with regards to outcome.

Is The Effect Size Found Meaningful?

The effect size for the primary outcome measure was a Cohen’s d of 0.86, Freeman et al (2021). The effect size for total delusions score on PSYRATS was d=1.2 Freeman et al (2021) celebrate this large effect size as comparable to that found in trials of CBT for anxiety disorders. But in terms of the primary outcome measure the average person undergoing CBT improved  by less than one standard deviation compared to the average person who was befriended, this is shown diagrammatically below, does this amount to a real world difference? The economic analysis promised in the pre-trial protocol was not included in the paper, leaving it an open-question as to whether the CBT is worth the added investment. 


Eminence-based Rather Than Evidence-based

Advocates of the Feeling Safe Programme, are claiming more than is known, doubtless BABCP and IAPT will seize on it and control how CBT is to be conducted with this population, extending their empire. Well the study was published in Lancet Psychiatry after all? The CBT therapist should be sceptical, but regrettably training courses seem not to equip them for this, I wonder why? Perhaps I am paranoid?

Dr Mike Scott