IAPT – The Need For A Product Recall

In response to David Clark’s blog ‘IAPT at 10’ on the NHS England website, I wrote: ‘If NHS England invited the manufacturer of a pharmaceutical to review the growth and successes of its’ drug over the last decade eyebrows would be raised. Yet this is precisely what has happened in asking David Clark to comment on his baby (IAPT) with whom he has an ongoing commitment and financial arrangement. In terms of publication bias his piece is off the scale.

No Independent Replication

There has never been independent replication of IAPT’s claim to 50% recovery. My own work, which is wholly independent of IAPT and was published in the Journal of Health Psychology   last year (see link below)  suggests a 10% recovery rate.

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

Questionnaires Rather Than An Independently Administered Standardised Diagnostic Interview

IAPT relies on questionnaires completed by clients with the full knowledge of the treating clinician, introducing a ‘demand’ element into the proceedings. Further there is in IAPT’s procedures no way of knowing that the questionnaire/s are tapping the disorder/s that are germane to the client. 

No Evidence of An Added Value To IAPT When Compared With Findings Before Its’ Inception

The changes in questionnaire scores observed in IAPT clients are no different to those observed on self-report measures administered to clients going through counselling before the advent of IAPT. The Mullin (2006) findings (see link below) are the appropriate counterfactual and indicate no added value to IAPT.

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

Clients present for therapy at their worst and some improvement with time would inevitably be visible on a questionnaire, IAPT has provided no evidence that clients given simply attention would not have shown the same changes to those observed.

The Jettisoning of Evaluation Guidelines

Entry into Pharmaceutical/Psychological Studies is governed by the administration of a standardised diagnostic interview. Outcome is determined by blind re-administration of the interview at the end of treatment and follow up. In line with this, an international team of Experts [Guidi et al (2018) see link below] have developed evaluation guidelines stipulating the need for blind independent assessment of psychological interventions. All IAPT generated studies have breached these guidelines.

https://www.dropbox.com/s/hizta38yqm4lfh3/Methodological%20Recommendations%20for%20Trials%20of%20Psychological%20Interventions.pdf?dl=0

Countries that do not look at psychological interventions through the lens of such evaluation guidelines will be taken in by IAPT’s marketing prowess. Unfortunately many such countries have shown such gullibility in the last decade.

Failure to Engage and Treat Clients

IAPT loudly proclaims the very large number of clients that it makes contact with but this is meaningless when their trajectory is considered. Half of those referred to or referring themselves to IAPT   have less than 2 treatment sessions.  The mean number of sessions attended for those who have 2 or more sessions is 6, there is no NICE approved treatment for a psychological disorder that requires just 6 sessions.  It is scarcely credible that IAPT is providing an evidence based treatment on any scale. There is an an independent re-analysis of the IAPT data in the link below

http://therapymeetsnumbers.com/is-iapt-too-big-to-fail/

A Failure of Governance

IAPT is essentially a QUANGO dependent on NHS England, and committed to expansion but without any observance of evaluation guidelines.  NHS England has taken IAPT’s claims at face value, as a consequence Clinical Commissioning Groups focus only on operational matter, numbers, waiting times etc with no focus on clinical matters in their interactions with IAPT. The National Audit Office conducted an inquiry into IAPT but has failed to publish its’ results. There has been a gross failure of governance by public bodies and their representatives.

Only The Voice Of IAPT’s Hierarchy Is Listened To

There has been no attempt by public bodies to independently seek the views of consumers of IAPT services. However an IAPT teacher, Jason Roscoe has publicly made a blistering attack on the service, see link below

https://www.dropbox.com/s/myz53dyn8zqhj13/Has%20IAPT%20become%20a%20bit%20like%20Frankenstein.docx?dl=0

He reflects ‘the gap between what the literature advises and what management allow seems to be widening leaving the patients as the ones who are being given sub-therapeutic, watered-down CBT’ and adds ‘The result? A revolving door where patients return in quick succession for multiple episodes of treatment with a different therapist each time…..not only this IAPT also seems to be making its own workers ill with reports of compassion fatigue and burnout not uncommon’.

The views of the 90 IAPT clients I examined were almost wholly negative and indicated the need to transform IAPT see link below

https://www.dropbox.com/s/zhr1fkg71aqvno0/Transforming%20IAPT.pdf?dl=0

IAPT The Need For Product Recall

There are such serious doubts about what IAPT has delivered over the last decade, that if it were a piece of machinery the product would have been recalled. A decade ago I wrote a book on how CBT can be delivered, with fidelity to evidence based treatment protocols, [Scott (2009) Simply Effective Cognitive Behaviour Therapy, London: Routledge], there is a pressing need to review such provision. In private communication with David Clark I have acknowledged that my approach would make the assessment process more costly. However the evidence of the past decade is that it is not possible to make a real world difference to client’s lives without closely following the procedures involved in randomised controlled trials of CBT. Departure from reliable assessment, diagnosis, advice/treatment results in a failure to translate efficacious treatments to routine practice’.

Unfortunately NHS England only permits upto 1000 character comments on their invited blogs, so essentially only the 1st paragraph of this blog will likely appear.

Dr Mike Scott

All IAPT Generated Studies Breach Evaluation Guidelines

An international team of Experts led by Jenni Guidi et al (2018) (see dropbox link) has recommended that for all trials of psychological interventions ‘Assessments should be performed blind before and after treatment and at long-term follow up’. But IAPT have been it seems “totally blind” to this need for independent standardised assessment. In the US, without at least alleged independent reliable assessment drug companies would not be allowed to market their wares. However it is apparently OK in the UK to market psychological interventions without any reliable determination of the proportion of people who are ‘well’ (no longer meeting recognised diagnostic criteria for at least 8 weeks, as assessed by a blind independent assessor).

https://www.dropbox.com/s/hizta38yqm4lfh3/Methodological%20Recommendations%20for%20Trials%20of%20Psychological%20Interventions.pdf?dl=0

But IAPT is not the only culprit, many of the randomised controlled trials compared CBT to waiting lists, as opposed to attention control groups and probably no more than half used independent blind assessors to assess outcome. This makes the evidence base for CBT more questionable than NICE would suggest. Additionally many of the evaluations of medication do not involve a long term follow up.

Dr Mike Scott