People Cannot Benefit from a Treatment To Which They Have Not Been Exposed – The Undermining of IAPT

The Improving Access to Psychological Therapies (IAPT) Service does not assess treatment fidelity. Thus, there can be no certainty that clients receive an evidence-based treatment treatment.  IAPT therapies are not EBTs. Despite this, the major funder of IAPT training days SilverCloud, claims on its’ website ‘up to a 70% real-world recovery’ using its computer assisted products, for all common disorders except PTSD and OCD!  The Advertising Standards Authority need to look at this, the ASA has a complaints form that can be completed online. SilverCloud’s UK address is Suite 1350, Kemp House, 152 City Road, London, EC1V 2NX., My own study of 90 IAPT cases suggests just a 10% recovery rate, Scott (2018) https://doi.org/10.1177%2F1359105318755264).

IAPT have produced no evidence that its’ therapists using SilverCloud make any added difference to their clients over and above that of those who didn’t use it. see SilverClouds Space for Depression programme   NICE Guidance ‘Space from depression for treating adults with depression’ Medtech innovation briefing published May 7th 2020. Strangely the NICE IAPT Expert Panel concluded that the case for adoption is ‘partially supported’ despite in the body of report noting lower depression scores, at the end of treatment for the clients of therapists who did not use the computer assisted CBT. An example of spin and conflict of interest.

 

The SiverCloud website cites 10 references appearing in peer-reviewed journals to support its work.  But none of the studies cited by SilverCloud involve blind independent assessors of outcome using a ‘gold-standard’ diagnostic interview. In the cited review study by Wright et al (2019) Wright JH, Owen JJ, Richards D, et al. Computer-assisted cognitive-behavior therapy for depression: a systematic review and meta-analysis. J Clin Psychiatry. 2019;80(2):18r12188 the third author is employed by SilverCloud.

 ‘Real-world’ recovery represents a change that a client would care about, such as no longer suffering from the disorder that they were suffering from before treatment or a return to best functioning. In a footnote SilverCloud defines recovery as ‘Moving from clinical caseness to non-caseness, i.e. lowering the score on PHQ-9 and GAD-7 from above the clinical threshold to below the threshold’. Such changes are meaningless to clients they are not ‘real-world’.

Here is what one client told  me:

‘I found Silvercloud ineffective, generic and not tailored to my personal situation. It wasn’t engaging or helpful and as such I didn’t engage with the website very much. Consequently, the following weekly call with the IAPT therapist  were sometimes made difficult by the fact I hadn’t completed the same questionnaire as the week before or read through articles. I wanted to talk about my situation, my feelings and find out why I was feeling the way I was, but I felt I was just being led back to using the online SilverCloud resource.

‘It was in 2017 that my doctor suggested I try SilverCloud online CBT with telephone support and in September 2017, I started speaking to another IAPT counsellor. He seemed to be a very nice man. After a few weekly calls, he stated that he didn’t believe I was depressed and so he changed the original Silvercloud course I had started and reset it back to a new series of 6 sessions. The weekly calls lasted between 20 minutes to an hour depending on what we discussed, but always concluded with him asking me to log onto SilverCloud and work my way through the programme before our next call. After the requisite 6 sessions finished in February 2018, that was it! No answers, no tools to help me cope, just signed off, discharged, but told I had 12 month access to SilverCloud. I haven’t used the resource since’.

In general the claims of clinicians and supervisors with regards to treatment fidelity do not match those of independent blind-raters [ Waltman et al (2017)https://doi.org/10.1016/j.janxdis.2021.102407], there are vested interests at play.

The author knows of no study of low intensity CBT (guided self-help, group psychoeducation, computer assisted CBT) that has assessed treatment fidelity. Usage of a manual does not guarantee treatment fidelity. Approx. three quarters of IAPT clients receive low intensity intervention on entry to the Service [Davis et al (2020)https://doi.org/10.1136/ebmental-2019-300133].].

IAPT’s approach ostensibly depends on the results of randomised controlled trials of CBT, but a study of remission rates in CBT for anxiety disorders (including OCD and PTSD) Levy, Bryan and Tolin (2021) https://doi.org/10.1016/j.janxdis.2021.102407 showed that in half the studies (8 out of 17) there was a high risk of bias because of a failure to address treatment fidelity. Further in 7 of the 17 studies there was a high risk of bias because of the failure to use blind assessors. [A re-view of psychotherapy trial reports published in 6 top psychiatry journals in 2017 and 2018 revealed that only 59% of the included trials reported adequate blinding of outcome assessors Mataix-Cols et al (2021)]. https://jamanetwork.com/journals/jama/fullarticle/10.1001/jamapsychiatry.2021.1419?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamapsychiatry.2021.1419].Thus, the research base that IAPT draws upon is far from rock solid.  The remission rate in rcts for anxiety disorders is approx. 50% [ Springer et al (2018) https://doi.org/10.1016/j.cpr.2018.03.002]and this is the ‘gold standard’. But IAPT claims comparable results despite a total disregard for blinding and treatment fidelity! The faked goods ought perhaps to be reported to Trading Standards as well as ASA, in lieu of any interest in the matter from the British Psychological Society (BPS) or the British Association for Behavioural and Cognitive Psychotherapy (BABCP)!

The real story of SilverCloud is that it provides morsels of CBT when what is really needed is a proper meal. It is insulting to clients to in effect say ‘let’s see how you get on with morsels and then we will see about a proper meal’.

 

Dr Mike Scott