of a 50% recovery rate. The Editors of Lancet Psychiatry https://doi.org/10.1016/ 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, https://doi.org/10.1016/ 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:
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. https://doi.org/10.1016/S2215-0366(21)00083-3
Boyce, N., Graham, D., & Marsh, J. (2021). Choice of outcome measures in mental health research. The lancet. Psychiatry, 8(6), 455. https://doi.org/10.1016/S2215-0366(21)00123-1
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. https://doi.org/10.1177/1359105318755264
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.
Joan Marsh MA PhD
Dr Mike Scott