Tag: Guided self-help

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Mis-Guided Self Help In IAPT

A just published study by Duhne et al (2022)found that almost a third (29%) of those assessed by the Improving Access to Psychological Therapies Service (IAPT) and referred to Guided self-help (either face to face or computer assisted CBT) did not attend any treatment sessions. Whilst of those who attended treatment over half (54%) dropped out, defined as attending three or less treatment sessions. These figures are much higher than the 20% Swift and Greenberg (2012) of clients who typically dropout of psychotherapy.

 

Curiously the authors miss the obvious implication that GSH is misguided. Instead they recommend further investigating an algorithim for better matching those who would do better in cCBT or better in face to face! Why is this? The authors declare no conflict of interest, but the Department from which it emanates at Sheffield University has a long list of IAPT teachers. There is a complete absence of critical appraisal of IAPT’s metrics suggesting that the Sheffield researchers don’t want to bite the hand of a service that gives them a ready-made data set, it eases the research burden. The Journal in which it was published Behaviour Research and Therapy characteristically ignores any criticism of IAPT.

 

Concluding anything  about the relative merits of cCBT and face to face GSH is problematic, in the Duhne et al (2022) study as the mean initial PHQ9 scores  were respectively 12.32 and 15.01, which is statistically significant p < 0.0001, when the sample sizes and standard deviations  are input into a the MedCalc comparison of means calculator.  This suggests some systematic bias in the allocation of people to these modalities. 95,088 patients accessed diverse low-intensity interventions: GSH (n = 84,503; 88.4%), psychoeducation groups (n = 8671; 9.1%), cCBT (1611; 1.7%), and other interventions (n = 753; 0.8%). 

Dr Mike Scott

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IAPT’s Below Intensity CBT Revolution

IAPT’s low intensity CBT should be re-branded ‘below intensity CBT’, as all the methodologically rigorous CBT outcome studies were conducted  on full dose CBT.  Guided self-help (GSH) interventions were first recommended by a NICE committee in 2007 and 2009 for depression and the anxiety disorders. In its’ wake IAPT enthusiastically adopted GSH such that by 2018, 70% of clients were being given it. But recently therapists have been told not to use the term ‘GSH’ but talk to clients instead of ‘low intensity CBT’. This re-labelling appears to have occurred because of the difficulties of engaging the public in this more obviously cheap option (see previous post).

But NICE did not conduct a systematic review of the outcome literature, rather its’ recommendations were simply the advice of its’ committee. It failed to acknowledge that there were no studies of ‘guided self-help (GSH)’ with a hard outcome measure i.e studies involving an independent blind assessor using a standardised diagnostic interview. Thus there was no evidence that the man/woman in the street would recognise that the GSH had returned them to normal functioning. However the recommendation of NICE was that the low intensity interventions had to be matched to the particular depression or anxiety disorder. But IAPT took what it wanted from the NICE guidance, jettisoned making a diagnosis and proclaimed that appropriate treatment could follow a problem descriptor, without any empirical evidence for the latter.  The upshot is that for a decade IAPT clients have largely been subjected to ‘below intensity cbt’.

There has been a decade of ‘the below intensity CBT’ revolution and it has failed. This is not to say that there may not be cheaper effective options for service delivery such as group CBT, but the scope for such interventions is limited to depression and some anxiety disorders and much more methodologically rigorous outcome studies are necessary to confirm its place.

Dr Mike Scott 

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The Care Quality Commission (CGC) Is Being Duped by IAPT

IAPT is camouflaging what most of its clients receive and has eskewed a focus on clinically relevant outcomes. But one of the domains that the CQC assesses services against is whether they are Outcomes-focused. The CQC needs to conduct an inquiry into IAPT.

Guided Self-Help (GSH) has been the diet of 71% of IAPT’s clients, but therapists have now been advised not to mention GSH, because it may be off-putting! But rather to refer instead to ‘low intensity telephone CBT’ . Notwithstanding that NICE has justified its’ support for low intensity CBT on the basis of studies that were termed ‘GSH’. There is a transparency about offering GSH, clients have a right to know what they are letting themselves in for. Informed consent cannot be meaningfully given to a term like ‘low intensity telephone CBT’.

The matter of informed consent is compounded further by IAPT by their failure to inform clients of what clinically relevant outcome he/she can expect. In particular what minimally important difference the client can expect and clearly see as meaningful. Changes on a psychometric test do not qualify as a clinically relevant outcome by contrast a client can clearly understand say an expectation to be back to their usual self.

IAPT’s ‘low intensity telephone CBT’ itself rests on a fault line, studies that found statistical significance between groups e.g computer assisted CBT vs waiting list, but without a) any discussion of the clinical relevance of the findings and b) blind independent assessment of outcome. Dissemination of the low intensity interventions has been promoted on the back of statistical significance rather than clinical relevance. This makes it imperative that the CQC becomes outcomes focused in a transparent way and is not sucked in by IAPT’s self serving surrogates.

Dr Mike Scott

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Guided Self-Help In IAPT Breaches Informed Consent

‘That self-help is not a regular treatment should be clear from the beginning…A self-help intervention cannot replace more usual forms of psychological treatment and this should be made clear from the beginning’ so writes Pim Cuijpers in the most recent issue of Clinical Psychology Science and Practice

https://www.dropbox.com/s/4d9z23p1xttv7nl/Cuijpers-2018-Clinical_Psychology%253A_Science_and_Practice%20ethics%20guided%20self-help.pdf?dl=0 ,

but it never is in IAPT.

 

Cuijpers points out that guided self-help (GSH) for depression has a small effect size around 0.28 and this is substantially less than the O.6 or higher of traditional psychological treatments https://www.dropbox.com/s/3zgy50ub5s5q1yx/Lewinsohn%27s%20Coping%20with%20Dep%20Meta-Analyses.pdf?dl=0.

Further the impact of GSH may be even less when compared to active control conditions as opposed to the common comparisons that have been made with inert waiting lists. In addition a diagnostic interview has been used in only at most half of the GSH studies.

It is unethical not to let clients know that what they will most likely receive initially in IAPT is a substandard treatment. The risks and benefits of any procedure need to be clearly spelt out for informed consent. Service users are entitled to provider track record information. There would appear to be grounds for complaint from former IAPT clients, whether to NHS England or perhaps via a lawyer. The NHS guidance on consent to treatment states ‘the person must be given all the information in terms of what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment doesn’t go ahead’.

Dr Mike Scott