Health Anxiety, Covid-19 and Overwhelming Services

great article in the Journal of Anxiety Disorders  by Asmundson and Taylor just published on this https://doi.org/10.1016/j.janxdis.2020.102211. The authors remind us that we can have too little health anxiety, for example leading a person to ignore requests for social ill distancing, but also too much for example panic buying sanitisers. The article reflects that there may be an overall increase in health anxiety as a consequence of the pandemic. This will likely lead to an increase in referrals.  

If everybody with a current health concern were invited to book a telephone assessment with IAPT or ring Mind,  ( I hear that the Government have given £5million to Mind) the services would be overwhelmed. But not only this, what direction would people be signposted to, and on what basis? The DSM-5 uses the term ‘Illness Anxiety Disorder’ , rather than ‘health anxiety’, its criteria help decide on whether a person is a ‘suitable case for treatment’ or a member of the ‘worried well’.  Helpfully it offers signposts, implying a ‘wait and see’ approach in our current situation with its criteria that an illness anxiety disorder’ label should not be applied  unless the ‘illness-related preoccupation has been present for at least 6months’ implying a normality of upsetting responses before this. Another of the criteria  is that ‘there needs to be ‘a preoccupation with a having or acquiring a serious illness’  [in the DIAMOND interview for DSM-5  https://giving.hartfordhospital.org/tolin-diamond-training-video this is operationalised as an hour or more a day as being clinically significant]. A further requirement is that there should be significant functional impairment in domestic or work roles as a consequence of the health preoccupation. The criteria help stop the pathologising of normality and make for a better use of scarce mental health resources.

But though CBT is recommended for health anxiety I could find no study in which clients had been independently evaluated to see if they were no longer suffering from what has been termed variously ‘hypochondriasis’, “health anxiety’ and now ‘illness anxiety disorder’ at the end of treatment, much less at follow up. So some humility is called for when, as is likely, CBT is vociferously advocated as a response to this pandemic. But the prospect of increased funding is likely to be too attractive to agencies.

 

Regards

 

Dr Mike Scott

 

 

Test Those With Symptoms – A Message From The Pandemic To IAPT

Without such testing for NHS staff we would be on the road to chaos. But the Government’s Improving Access to Psychological Treatment (IAPT) service  makes no diagnosis of clients,  directing them to whatever service the therapist deems fit. There is likely to be a myriad different IAPT responses to client’s presenting variously, anxious about developing the Corona virus, saddened that they could not properly say goodbye to a loved one who died of the virus (?PTSD) or distressed that they cannot visit a loved one. In jettisoning diagnosis IAPT has ceased to operate within the bounds of evidence based treatment (EBT). EBT is based on the belief that it is known  that certain treatments work for certain conditions under certain circumstances. This applies certainly to the common mental disorders and is reflected in the NICE Guidelines.

NHS England have failed to meaningfully document the personal consequences of IAPT’s ministrations. IAPT have engaged in a high risk operation of providing therapy on the cheap using largely low intensity interventions. This has understandably attracted a great deal of funds – it’s the answer to a power holders prayer. But there is no accountability if things go wrong, as they have. It’s like a repeat of the banking crisis, morally reprehensible. Unfortunately and understandably the NHS is pre-occupied with COVID-19 and I don’t see them addressing the issue in the forseeable future.

Dr Mike Scott

IAPT 10 NICE Guidance 0

a study by Barkham and Stone https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-018-1899-0 of over 33,000 IAPT cases has revealed high intensity counselling as being the most cost effective, requiring on average just 6 sessions compared to the 9 sessions for high intensity CBT, to achieve the same result. But the NICE Guidance  recommends CBT as the first line treatment not only for depression http://www.nice.org.uk/guidance/cg90 but also the common anxiety disorders. In the 2 years since the published study, IAPT appears not to have considered that there is likely something wrong with its’ data set when it provokes a conclusion at variance with the NICE Guidance. However it is IAPT that has muscle at the coal face, not NICE. The juggernaut of IAPT carries on, paying lip service to NICE Guidelines to placate NHS England and local Clinical Commissioning Groups.

The Barkham and Stone study also suggests that whatever of the 4 trajectories clients take in IAPT: 1. high intensity counselling (9%) 2. high intensity cbt (18%) 3. low intensity cbt followed by high intensity counselling (20%) 4. low intensity cut followed by high intensity cut (53%) there is no difference in outcome, all improve by 6 points on the PHQ9 each starting off at a score of 15. This would suggest that there are no meaningful distinctions between the categories and that the stepped care approach bears no fruit. Yet IAPT continues with stepped care. IAPT fails on quality control, it can provide no meaningful data with regard to treatment integrity i.e a guarantee that an evidence based protocol has been followed for a reliably identified disorder. Nor can it provide any evidence that the observed changes of score would not have happened with the passage of time and attention (an active placebo).

Regrettably IAPT, markets itself superbly with Ontario in Canada being the latest to be conned by the IAPT model, when will people wake up and smell the coffee.

 

Dr Mike Scott

Problem Descriptors – A Confusing IAPT Signpost Leading to Crashes

‘ I think it is social anxiety disorder, from my problem description my manager thinks its’ generalised anxiety disorder’  should treatment be determined by the power holder or should they just spin a coin with a ?50% chance of the client getting the right treatment. Such is the soap opera acted out in IAPT.

IAPT uses problem descriptors to determine what treatment to give to whom. But problem descriptors are a rule of thumb to determine treatment. In randomised controlled trials treatment was based on a reliable diagnosis, which would typically take an hour or more to determine. IAPT has come up with a problem descriptor shortcut of undetermined reliability and which it seeks to legitimate by asking therapist to provide an ICD-10 code.

The IAPT Manual considers it best practice if a service provides an ICD-10 code for at least 80% of cases. Can it be acceptable for up to 1 in 5 people to have rudderless treatment? When clients are assigned an ICD-10 code it is usually a single code and a Manager may advise that a another code is appropriate rather than the one the clinician selects.  Whilst the IAPT Manual advises that more than one code can be appropriate, it also advises that treatment should be dictated by the principle problem, this likely has the effect of making for single awards of ICD-10 codes.

The IAPT Manual claims that ICD-10 codes are the basis of the NICE recommended treatments, but they are not. Most of the mental health trials considered by NICE are based on the more reliable and stricter DSM criteria. Notwithstanding this ICD-10 provide diagnostic criteria for each disorder, but IAPT also contends that it does not make diagnosis. It is therefore difficult to escape the conclusion that IAPT pays lip service to ICD-10 codes for its’ own credibility.  Despite this the IAPT Manual insists that the treatment protocol should follow the identified problem but the protocols have never been matched to problems but to disorders!

Dr Mike Scott

 

‘We Are Not Going To Give You The Tools To Do The Job’ – IAPT Becomes INEPT

this summarises the blog https://notaguru.blog/2020/02/16/resilience-its-time-to-change-the-conversation/  from Low intensity Therapist,  James Spiers.

Yesterday I gave a one day workshop on ‘Getting Back to Me Post Trauma’, arranged by the Chester, Wirral and North Wales Branch of BABCP at Chester Rugby Club with over 65 attendees. It went down very well,  what was very striking was the level of demoralisation of IAPT staff, complaints of the numbers of contacts to be made, being hauled over the coals about recovery rates, the meaninglessness of the questionnaires completed and the powerlessness of staff to get their employer to listen. Will do a blog on the Workshop shortly.

 

Dr Mike Scott

£4 billion Spent On IAPT and National Audit Office Says ‘Value For Money’ Is Not Our Concern

and we  have ‘no plans to revisit work’. This was the National Audit Office’s response to a Freedom of Information Request to my colleague Joan Crawford on February 18th 2020 http://FOI-1298.  The NAO’s response continues our ‘purpose was to establish the relevant facts’ with regards to waiting times. The NAO adds it was these concerns expressed by an NHS staff member that first led to the NAO inquiry.  Curiously the NAO  then says  it was planned to describe the responsibilities of different health sector bodies  ‘in assuring and overseeing the accuracy and integrity of the reported data’ but the NAO has never addressed the ‘integrity’ of the data. The NAO has failed to tell anyone that the unit of analysis in IAPT’s own data set, the proportion of people who recover, is suspect. Whilst IAPT claims a 50% recovery rate my own independent analysis submitted to the NAO suggests it is just 10%.  The NAO curtailed its’ investigation in June 2018 because of ‘changing priorities’, leaving its’ findings unpublished and duties undischarged. There is a pressing need for independent audit. 

On the same day as the FOI response, the Government announced that it will spend £2.6 billion over 6 years on flood defences and that every £1 spent will save £8. However the UK Government has failed to ensure that the NAO furnishes it with similar data. Without such data there is no real world accountability.

 

Dr Mike Scott

DWP Scores Claimant With Multiple Diagnoses As Zero Impaired And She Loses Benefits

and suffers a depressive reaction. I was preparing a desktop report for Ms X just as a National Audit Office (NAO) Report into the DWPs procedures was announced. It revealed that the DWP were investigating 69 cases of suicide following cessation of Personal Independence Payments (PIPs). The NAO observed that the true extent of suicide in this context is unknown. It is time to put the mental sequelae of DWPs decisions on the agenda.  

Extensive documentation on Ms X reveals recurrent depressive disorder, autism and adult ADHD, together with years of contact with secondary care mental health services. Despite this the DWP assessor indicated that she had 0 problems communicating and interacting with others! Reading his letter of justification he relied entirely on his perception of how she presented at interview.  He gave a total Summary score of 0 which is simply preposterous, whether or not she had sufficient points to meet the PIPs criteria. I have written to the DWP for a review of the case.  I have also suggested that not only should suicides be subjected to an Internal Process Review but all Claimants who are judged to have scored 0. Such a change in PIP score is near miraculous as people are awarded PIPs initially because of enduring functional impairment. But IPR’s are not open to public scrutiny and the NAO pointed out that it is not known whether such reviews have led to any change in practice: There is a need for transparency, I await with interest the DWP’s response to my letter.

Unfortunately the DWP’s assessor has adopted the style of  most mental health professionals, reliance primarily on a single source of data (IAPT on self report measures of doubtful relevance ) or the clinicians take on the client’s story with an open ended interview.  This results in missed diagnosis, mistreatment and misleading statements about the client’s diagnostic status.

Dr Mike Scott

 

 

 

 

 

 

IAPT’s Mistreatment Of Those With Medically Unexplained Symptoms (MUS)

in our paper published today in BMC Psychology, Keith Geraghty and I write of Improving Access to Psychological Therapies (IAPT) malpractice with MUS clients , see link  https://doi.org/10.1186/s40359-020-0380-2

A series of seven core problems and failings are identified, including:

  1. an unproven treatment rationale
  2. a weak and contested evidence-base
  3. biases in treatment promotion
  4. exaggeration of recovery claims
  5. under-reporting of drop-out rates
  6. a significant risk of misdiagnosis
  7. inappropriate treatment.

We concluded that:

There is a pressing need for independent oversight of this service, specifically evaluation of service performance and methods used to collect and report treatment outcomes. This service offers uniform psycho-behavioural therapy that may not meet the needs of many patients with medically unexplained health complaints. Psychotherapy should not become a default when patients’ physical symptoms remain unexplained, and patients should be fully informed of the rationale behind psychotherapy, before agreeing to take part. Patients who reject psychotherapy or do not meet selection criteria should be offered appropriate medical and psychological support.

Dr Mike Scott

Audit of Secondary Care Psychological Therapies Fails Clients

The National Clinical Audit of Anxiety and Depression (NCAAD) has just been published https://www.rcpsych.ac.uk/members/your-monthly-enewsletter/january-2020-enewsletter/anxiety-and-depression-report?dm_i=3S89,13323,2H3J22,3SCFB,1 but it is impossible to gauge from it what proportion of those with anxiety or depression recovered with psychological treatment. There was no reliable methodology employed to determine what constituted a ‘case’ of anxiety or depression and there was no independent evaluation of outcome. 

No evidence is provided that psychological therapy made a real world difference to client’s lives.  The authors reported that 75% of service users agreed that their therapy helped them to cope with their difficulties, with 88% agreeing they were treated with empathy, dignity and kindness.  The average number of treatment sessions attended was 13. Having made such a time investment clients  are unlikely to be critical of the service they received particularly, as was usually the case, the therapist was judged a nice person. 

The report opines that 65% of service users were receiving a type of therapy in line with NICE Guidance for their disorder. But given that diagnostic status was not reliably determined there can be no certainty that an appropriate NICE protocol was used. There is nothing in the report to indicate that treatment records were reviewed (or capable of review) in such a way as to determine matching treatment targets, strategies and disorder. This makes one sceptical of the authors claim that the main intervention was CBT, it is alleged CBT. With just over a half completing the planned number of sessions. With a further 1 in 3 people receiving a type of treatment that was not NICE compliant even by the standards of the authors of the report.  

The authors call for an increased use of psychometric tests (no test was used in more than 15% of cases) and a reduction of waiting times (almost half waited over 18 weeks). Doubtless these are laudable aims but of themselves are unlikely to make any real world difference to client’s lives.

There is a legitimation of current practice, with implicit claims for more funding and better training, all horribly reminiscent of the failed IAPT service.  The National Audit Office needs to not only re-ignite its’ inquiry into IAPT but also determine whether secondary care psychological therapy is value for money – the NCAAD provides no evidence of the latter.

Dr Mike Scott

 

NHS Improvement Reveals Hole in IAPT’s Bucket

but the NHS has taken no steps to stop the haemorrhaging of clients and money.  A quarter (25.3%) of IAPT’s expenditure in 2017-2018, £75.58 million, was devoted to clients who were either not assessed or were not put in any care cluster (groups of diagnoses), according to the National Schedule of Reference costs see link https://www.dropbox.com/s/3xlu6tipaeguk2c/FOI%20IAPT%20data.xlsx?dl=0

which I acquired through a Freedom of Information Request. Curiously only 15.2% of IAPT’s expenditure, £45.68 million in 2017-2018 went on common mental health problems of low severity, whilst £176.86 million (58.99%) was spent on non-psychotic disorder.

For those with common mental health problems of low severity there were 214,863 high intensity contacts compared to 378,617 low intensity contacts. Thus low severity often appears to necessitate high intensity contacts, this raises questions about the reliability of ‘common mental mental health problems of low severity’ category.

For non-psychotic disorders 1.075 million high intensity contacts were delivered and almost as many low intensity contacts, 0.876 million. Assuming that the those categorised as a having a non psychotic disorder are more functionally impaired than those with common mental health problems of low severity, why are they having so many low intensity contacts? Sticking plasters for serious injury! It is time for the National Audit Office to restart its’ inquiry. 

 

Dr Mike Scott