and the added value of low intensity IAPT is?

compared to how people would have got on anyway if not referred to IAPT (in economist terms the appropriate counterfactual), the ‘added value’ has not been demonstrated. Yet most people receive a low intensity intervention such as computerised CBT, guided self help or groupwork.

I could find no independent outcome assessors involved in the randomised controlled trials of low intensity interventions that the NICE guidance largely relies on. Instead reliance has been placed on IAPT’s marking and marketing of its’ own homework.

In a review of randomised controlled trials published in 4 medical journals Kahan, Rehal and Cro (2015) only a quarter (26%) involved blinded outcome assessment. These authors write ‘Previous reviews have found that unblinded outcome assessment can lead to estimates of treatment
effect that are exaggerated between 27% and 68%’ see link below:

https://www.dropbox.com/s/aarqu8j95udwmpl/Blinding%20independent%20assessment%20rare%20%202015.pdf?dl=0

But the position appears worse when it comes to psychological therapies with no reliable rcts for low intensity interventions, and with regards to high intensity interventions the few blind outcome assesments are clustered around depression, the anxiety disorders and PTSD. Since the millenium there has been a drift away from the use of outcome assessors, this makes research cheaper, it is much easier to massage statistics to give a positive hue, the originators of an intervention and those with a vested interest are given a free hand.

Researchers on IAPT [seee Bower et al (2013)] play fast and loose with Cochrane risk of bias tool, see link below:

https://www.dropbox.com/s/bmr98o8z8fcfuzv/paths%20to%20mh%20Cochrane%20Risk%20of%20bias%20assessment%20tool.pdf?dl=0

and jettison the need for independent blind assessment implicit in the tool on the spurious grounds that ‘most outcomes are self-reported’ see link below:

https://www.dropbox.com/s/24qz5pdu6dfl0ce/Low%20intensity%20initial%20severity%20doesnt%20make%20a%20difference%202013.pdf?dl=0

Looked at from the perspective of independent outcome assessment the claims for low intensity interventions look spurious and the evidence base for high intensity interventions is more circumscribed than BABCP conferences or IAPT would suggest.

The IAPT Manual published last year recommends extension of the service to irritable bowel syndrome, chronic fatigue syndrome, chronic pain and medically unexplained symptoms not otherwise specified but makes no mention at all of the need for independent blind assessment of outcome, instead it suggests simply what self-report measures should be administered. See link below:

https://www.dropbox.com/s/pgmbsoqjqmq04qz/IAPT%20Manual%202018.pdf?dl=0

Yet another marketing opportunity, when we need real world answers, how many people said to an impartial observer that they were back to their usual selves after the intervention? how long did this last?

Dr Mike Scott

IAPT Have Reinvented The Wheel

if there was no IAPT the outcome for treatment of primary care clients would be just the same. In 2006 (before IAPT) Mullin et al examined the effects of counselling/therapy in more than 11,000 clients and concluded that between 5 and 6 clients out of every 10 met the criterion for recovery. These authors used the same criterion with regard to the reliable change index as used by IAPT, but used the CORE-OM self-report measure rather than the PHQ9/GAD7. If anything the Mullin et al (2006) results are slightly better than IAPT’s claimed 50% recovery.

Economists evaluate the worth of a service by comparing it with its non-existence (the appropriate counterfactual), the Mullin et al (2006) study suggests that at the very least there is no added benefit to IAPT.

Thanks to Barry McInnes for alerting me to the Mullin et al (2006) study

https://www.dropbox.com/s/8a4qv5r13rotkyy/Appropriate%20Counterfactual%20Mullin%202006.pdf?dl=0

Clinical Commissioning groups need to be made aware of this. If psychological therapists were employed by the GP practice there would be obvious accountability to the GPs. At present accountability is solely to a QUANGO with its’ own agenda. It is a scandal that the National Audit Office has not published the results of its enquiry into IAPT. Perhaps a collusion of Quangos.

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