IAPT – Suicidal and Given Online CBT

 I recently came across a former IAPT client that the Organisation’s own documentation described as considering two different means of suicide. He had been bullied at school and engaged in a lot of self-harm. This depressed young man was given computer assisted CBT by IAPT and dropped out after 4 sessions. He told me that it did not teach him anything he did not already know. IAPT’s decision making is based on exigencies rather than clinical need.

Oftentimes a client with thoughts that they would be ‘better off dead’ are passed back to their GP. The GP is then obliged to contact the patient to discover that the ‘suicidal thoughts’ are most often passive and without any active intent or planning. In such instances IAPT had not taken the time to discover whether there was any active planning of suicide. The reaction of the Organisation is that ‘we do not want egg on our face’, so bounce it back to the GP. Unfortunately GP’s don’t complain to their Clinical Commissioning Groups about IAPT, content that they get a break from these ‘non-medical’ cases whilst they are being seen by IAPT, albeit that it is a revolving door.

Dr Mike Scott

Mental Health Patients and GPs Caught In IAPT’s Revolving Door

30% of GP referrals to the Improving Access to Psychological Therapies (IAPT) service do not attend, and of those who attend for treatment, 40% do so for only one session [Pulse November 2nd 2018 Home Analysis NHS structures Revealed: How patients referred to mental health services end up back with their GP]. The GP is left to cope with this haemorrhaging , with no input from Clinical Commissioning Groups (CCGs) to rectify matters.  The CCGs are complicit in IAPT ‘cherry picking’ clients, refusing clients under another service, such as substance misuse or an eating disorder.  Further the CCG’s do not bat an eye when IAPT claims to have met its’ target of a 50% recovery rate.  They miss the point that there has been no publicly funded  independent audit of IAPT.  They are blissfully ignorant that using an independently administered standardised semi-structured interview (SCID) only the tip of the iceberg (9.2%) recover Scott (2018) https://doi.org/10.1177%2F1359105318755264.

Evidence based practice involves an integration of best research evidence, clinician expertise and patient’s preferences [ NHS England document ‘Finding the Evidence’ November (2013)].

There are no randomised controlled trials, using a blind evaluator, of IAPT’s modal, low intensity treatment.  Making  the ‘best research evidence’ leg unstable.  GPS do not audit the effect of IAPT on their patients and so their clinical expertise in dealing with these patients is questionable.  Shared decision making is an integral part of  eliciting patient preferences. But in IAPT clients are usually discharged when they have had the pre-determined number of sessions and/or when their score on a self-report measure falls below a certain cut-off.  There is no credible elicitation of client’s preferences. All legs of the evidence based practice stool have fault lines, and it collapses under IAPT’s weight. The Agency is a prime exemple of failed evidence based practice.

Dr Mike Scott

IAPT’s Black Hole – Accountability

I recently asked the National Audit Office to restart it’s investigation into IAPT. I am expecting their reply in the next week or two. There has been no independent scrutiny of IAPT. They have been answerable only to Clinical Commissioning Groups, which have consisted largely of GPs and allowed IAPT to mark its’ own homework.

But the accountability gap also extends downwards, where is the evidence that front line staff or clients have been consulted or involved in decision making?  Most recently IAPT has offered webinars, for its staff on helping those with long term COVID.   There is a tacit assumption that this will be within the expertise of IAPT therapists just as helping those with long term physical conditions such as irritable bowel syndrome. But the IAPT staff working with LTCs were never consulted, before this new foray. Client’s with LTCs were never asked whether they were back to their old selves (or best functioning) before this proposed further extension of IAPT’s empire.  

In the forthcoming issue of the British Journal of Clinical Psychology I have challenged IAPT’s account of its ‘performance’ see ‘Ensuring IAPT Does What It Says On The Tin’ https://doi.org/10.1111/bjc.12264. There is a reply in rebuttal see ‘The costs and benefits of practice-based evidence: correcting some misunderstandings about the 10-year meta-analysis of IAPT studies’ https://doi.org/10.1111/bjc.12268 that reveals a breathtaking level of conflict of interests. IAPT and its’ fellow travellers should be held to account. But importantly they also need to account to their therapists and clients. [ The original IAPT paper is available at https://doi.org/10.1111/bjc.12259]

 

Dr Mike Scott

IAPT’s Hall of Mirrors Feedback

negates improved practice. The Organisation’s usage of the Patient Experience Questionnaire (PEQ) violates all the key requirements for eliciting feedback, which has to involve:

a) a response to questions that have an unambiguous real world meaning e.g ‘are you back to your old self  since treatment? i.e questions have to have validity

b) drawing upon a consecutive series of clients

c) completion anonymously and not in the presence of the therapist

d) a representative sample.

IAPT makes a token gesture of soliciting feedback using the Patients Experience questionnaire,  but its’ modus operandi is such that it cannot furnish a body of evidence that would demonstrate that it is not a ‘world beater’. In effect it has operated with a confirmatory bias only seeking information that would confirm its’ prior belief.

In 2016-2017, of 219 Clinical Commissioning Groups in England, 55 (25%) produced no PEQ data at all, i.e that a quarter of CCGs were funding a service in the absence of any evidence that the IAPT Service was eliciting feedback. In 2017-2018 of the 554,709 clients who completed a course of treatment  only 22% Moller et al (2019) https://doi.org/10.1186/s12888-019-2235-z completed the treatment questions on the PEQ.

There is no evidence that IAPT took active steps to ensure completion by consecutive cases or that therapists were blind to the results of the PEQ. The questions on the PEQ are themselves of doubtful validity e.g ‘how satisfied are you with your assessment’, this  question presupposes that the client has the knowledge base as to what constitutes a good assessment, imagine  if asked this question as a possible COVID patient most of us would believe ‘it is outside my expertise to judge the matter’. The question on the PEQ ‘on reflection, did you get the help that mattered to you’ is ambiguous, is it asking about the emotional significance of the encounter with the therapist, for example did they really listen/seem to care or about whether as a result of treatment you had returned to normal functioning.

Government and Clinical Commissioning Groups have turned a blind eye to IAPT’s failure to systematically elicit feedback from clients. At a cost of £4billion over the last decade and an incalcu cost to mental health. sufferers.

Dr Mike Scott

 

 

Outcome In Talking Therapies – Calling a Spade a Spade

when did you last hear of a therapist asking a client ‘do those close to you think you are back to your old self now?’, ‘do you think you are back to your old self? ‘how long do you feel that you have been back to your normal?  Yet these questions reflect the implicit dominant concerns of clients. It is at a minimum, neglect not to ask such questions and we may come to see this failure at some future point as abuse.

But Improving Access to Psychological Therapies (IAPT) therapists typically concentrate on whether there has been an improvement of 6 points on the PHQ9, with no attention to how long the improvement has persisted and they are then ejected from treatment.  Client’s are not asked whether the said change on the psychometric test constitutes a minimally clinically significant improvement in their condition.  Nor is there any evidence that the chosen psychometric test is pertinent to the primary disorder for which they were seeking treatment. The typically administered PHQ9 and GAD7 are highly correlated and may not even represent separate constructs i.e depression and generalised anxiety, and by themselves are dubious vectors for directing treatment. 

It is a sleight of hand to claim that the 6 point improvement on the PHQ9 or indeed scoring below 10 at post treatment say anything meaningful about the client’s real world if the test is used outside the context of a standardised diagnostic interview that identified depression as the primary disorder. Using the psychometric tests out of such contexts has more to do with income than outcome. For the unwary such changes seem ‘significant’ but the same change is observed in clients followed up without psychological therapy [see Gilbody (2015)]. Unfortunately it has proven all to easy to dupe Public Health England and Clinical Commissioning Groups. At present it seems it is too embarrassing for them to admit they have allowed themselves to be hoodwinked for years.

 

Dr Mike Scott

The IAPT Fiasco – A Failure of Governance Over Talking Therapies

no one is available to answer, why over £4billion has been spent on the Improving Access to Psychological Therapies (IAPT) service without independent evaluation. There should be a call to action when the best available evidence indicates that only the tip of the iceberg of IAPT client’s recover https://doi.org/10.1177/1359105318755264. Which Government Minister is responsible? Does responsibility lie with Public Health England or NHS England? Are Clinical Commissiong Groups (CCG’s) simply acting under orders?

It is not good enough for the architects of the IAPT service to blandly assert it is a ‘world beater’.  There is no transparency with regards to decision making and implementation in IAPT. In the 3 years of cbtwatch no public powerholder has deigned to answer the concerns raised.  Media pressure did however evoke a response by IAPT’s, public advocates, Professors Clark and Salkovskis, who are hardly disinterested commentators, albeit that they are persuaders par excellence. Ministers, Public Health England and NHS England have maintained a deafening silence.

Interestingly the failure in transparency over IAPT resembles that of the handling of the pandemic. It is it seems impossible to discover who postponed testing.  There has been a parallel failure, over the last decade to publicly and independently test out recovery rates in IAPT.  My own findings are that the tip of the iceberg of service users get back to their usual selves.

We seem destined to go from one fiasco to another, but all it needs to avoid this scenario is honesty and care, it is fundamentally an ethical matter. This could start by taking the time to listen to what IAPT client’s are saying and to IAPT front line workers.

Dr Mike Scott

 

Unregulated Mental Health Service Has Run Away With £4 billion

Following a Freedom of Information request NHS Improvement confirmed to me yesterday that the the total cost of the Governments Improving Access to Psychological Therapies (IAPT) Service in 2017/18 was £394 million.  I had asked them for the annual cost of IAPT since its’ inception, but they said that they were unable to furnish such figures! The service is twelve years old, thus conservatively it has likely cost the taxpayer £4 billion. 

For Rail and Road we have a regulatory body the  Office of Rail and Road, that monitors the performance of Network Rail and the varying train operators, but for mental health there is no such independent regulatory body. IAPT polices itself, and makes unexamined claims of recovery rates to secure funding from Clinical Commissioning Groups, who have never performed an independent audit. In my own area, Talk Liverpool last October publicly claimed an 87% recovery rate  for those who completed treatment, unsurprisingly therefore the Liverpool CCG has increased its funding by 25% to 10 million in the coming financial year. My own research published in 2018 suggests an actual 10% recovery rate.

It is time that the Government and Dominic Cummings got to grips with this.

The dropbox link to the FOI  response is below:

https://www.dropbox.com/s/x5kza6e6bpft2b3/Scott%20Internal%20Review%20Decision%20Letter%2020.01.2020.pdf?dl=0

My own findings are in the dropbox link below;

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

more about these matters anon

Dr Mike Scott

Rely Solely On A Self-Report Measure To Hike Up Funding and Fudge Outcomes

the routine audit of mental health services such as IAPT, is based on client self-report measures such as the PHQ9.  This carries the implicit assumption that the cut offs by themselves meaningfully distinguish cases from non-cases.   Correspondence in this months British Journal of Psychiatry highlights how misleading reliance on a single self-report measure can be. One study using this methodology claimed two fifths of 11-15 year olds had mental health problems  but when in another study assessment was conducted using standardised diagnostic interviews and diagnostic criteria the figure was just 13.6%!. doi:10.1192/bjp.2019.225

Whilst claims of high prevalence rates might be good for funding purposes and placing mental health on the public agenda there is no real world change for clients, the powerholders are the only beneficiaries.

In October 2019 my local IAPT claimed 87% (Talk Liverpool Performance Data) of those who completed treatment recovered in the previous 12 months, making Talk Liverpool outperform all other IAPT services (a national claim of a 50% recovery)! I can only think that Talk Liverpool have looked with envy at how Liverpool FC outperforms  all other teams and has gone into delusional mode! My own    study of 90 IAPT clients that I assessed independently using a standardised diagnostic interview showed that only the tip of the iceberg recover, see link below:

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

Rogers and Bender have written about ‘the myth of the laser accuracy of cut offs’ in their seminal work ‘The Clinical Assessment of Malingering and Deception’ (2018) Guilford Press.  Clinical Commissioning Groups could do with lessons in all these issues when interacting with IAPT and stop displaying such breathtaking naivety. 

Dr Mike Scott

 

£3 Billion Spent On Talking Therapies For No Clear Benefit

when will the Government insist on an independent evaluation of the Improving Access to Psychological Therapies Service? These are the concerns raised in my just published paper ‘Ensuring IAPT Makes A Real-World Difference’ see link http://mhfmjournal.com/Inpress.html

The Key Messages are:

  • Over the last decade over £3billion has been spent on the UK
    Government’s Improving Access to Psychological Treatment
    programme, without any independent assessment of outcome.
    • IAPT claims a 50% recovery rate but other evidence suggests
    that only the tip of the iceberg recover.
    • Expansion of IAPT beyond its remit of depression and anxiety
    disorders should be halted, until it has been demonstrated
    that it adequately performs its’ core task.

Clinical Commissioning Groups are being defrauded by IAPT’s claimed recovery rates

Dr Mike Scott

Mental Health – Propaganda For IAPT and Antidepressants Far Outstrips Evidence of Effectiveness

a just published editorial in Psychological Medicine 1–10. https://doi.org/10.1017/S0033291719003295 indicates that it is  doubtful that antidepressants exert a clinically significant effect compared to being on a waiting list for depressed patients. Strangely the editorial goes on to recommend IAPT as an addition to antidepressants. But there are major problems with this a) the effect of IAPT has never been compared to a waiting list b) IAPT clinicians do not make a diagnosis, so that it is unknown whether IAPT makes a difference for depression c) there has never been an independent evaluation of IAPT. In fairness to the writers of the editorial they do suggest halting the embrace of IAPT until the Service demonstrates that it has a long term effect.  NHS England and Clinical Commissioning Groups should at least heed this latter point. 

here is my 5 minute interview with BBC TV, https://vimeo.com/316124732

and a link to the waiting list  investigation by BBC Radio 4 last week:

https://www.bbc.com/news/health-50658007

the main points of my interview are:

  • only the tip of the iceberg of those attending IAPT fully recover https://journals.sagepub.com/doi/10.1177/1359105318755264 this contrasts with the Organisations claim of a 50% recovery rate
  • IAPT has only ever marked its’ own homework, despite over £3 billion being spent on it in the last decade. There has been no independent assessment of outcome, of the quality that would be expected were the effectiveness of a drug was being evaluated
  • IAPT fails to effectively engage and treat people. The IAPT Annual Report (2018)/2019] see link below, reveals that a third (31.2%) of new referrals drop out before treatment and approximately two thirds (61.1%) do not complete a course of treatment (using IAPT’s liberal definition of treatment as attending 2 or more session) with almost a third (29.54 %)  attending only one treatment session.

    https://www.dropbox.com/s/hwn9ncuuyds8qfa/IAPT%20Annual%20Report%202018-2019.pdf?dl=0

  • the most common gateway into IAPT is via a 20-30 minute telephone assessment with the most junior members of staff who are trained to signpost people via problem descriptors they do not make diagnoses
  • most IAPT clients do not get psychological therapy rather they are given either guided self help, computerised cbt or invited to attend a class/group i.e they receive low intensity interventions which are without the evidence base of the psychological therapies (high intensity)

Dr Mike Scott