If Santa lost half his deliveries before reaching the 2nd home on his itinerary, he would be viewed with suspicion. But last year the Improving Access to Psychological Therapies Service (IAPT) lost 46% of clients before their 2nd treatment session. What’s going on?
The Service would prefer to deftly switch attention to treatment completers, defined as those who complete at least two treatment sessions. But no Oncology or Physiotherapy service would define completion of treatment in such a minimalist way. This looks like sleight of hand. Nevertheless for ‘completers’, IAPT offers the defence of effectiveness across a range of disorders as evidenced by the effect sizes in the Table below:
IAPT’s Defence By Disorder
|
Within Subject Effect Size using PHQ9 (for all cases initially at caseness) and only for those who completed two or more treatment sessions. The ES is pre-treatment mean minus the post-treatment mean/pooled standard deviation |
|
|
Depression |
1.5 |
|
Agoraphobia |
0.8 |
|
Body Dysmorphic Disorder |
1.2 |
|
Generalised anxiety disorder |
1.0 |
|
Hypochondriacal disorders |
0.9 |
|
Mixed anxiety and depressive disorder |
1.2 |
|
Obsessive-compulsive disorder |
0.9 |
|
Other anxiety or stress related disorder |
1.2 |
|
Panic disorder [episodic paroxysmal anxiety] |
0.9 |
|
Post-traumatic stress disorder |
1.1 |
|
Social phobias |
0.9 |
|
Specific (isolated) phobias |
0.8 |
The mean ES in the above table is 1, this means that at the end of treatment the average client is better than 84% of those at the start. But it is not known how long this change lasts or what proportion of clients would consider themselves back to their old self. No independent person has asked them. The results are based on questionnaire responses made in the presence of the Santa like therapist. Who wants to displease Santa?
Science Has Progressed By Categorisation but IAPT Feigns This
The IAPT Manual states that its’ staff do not make diagnoses. How then are the IAPT staff supposed to know which label to attach to whom? It can be contended that the diagnostic labels don’t matter, but that is not what NICE says, they recommend specific protocols for particular disorders. IAPT has been dishonest since its’ inception, in claiming NICE compliance. It should publicly admit that its staff excercise unbridled clinical judgement in choosing a ‘diagnostic’ label. As a consequence the treatment it serves up is necessarily idiosyncratic. There is know knowing what this Santa will deliver!
IAPT squeezes its clients into 12 categories, one of which mixed anxiety and depressive disorder is still used despite the advice in the 2019 Manual. No room at the inn for those with an adjustment disorder, personality disorder, bulimia, substance dependence, bipolar or psychosis. The injunction from the Service is to treat the principal disorder, but comorbidity is the rule rather than the exception. The implication is that comorbidity is best ignored. Clients are made to fit the Service and not the other way round.
The Demise of The Supposed Medical Model and The Rise of Autocracy
There are many who see the ‘medical model’ as totally anathema and who should therefore be rejoicing at the de facto ignoring of diagnosis in IAPT. But they do so under their breath, as the prime movers in the development of the IAPT service, based their reputations on the efficacy of specific protocols for particular disorders e.g panic disorder.
The IAPT service is actually an experiment in determining what happens to clients if clinicians have free reign to treat clients as they see fit. The results of this clinician autocracy (or oligarchy if those who hold sway in IAPT/BABCP are considered) is that clients do not improve by any more than would be expected with the passage of time and attention.
The successors to Clinical Commissioning Groups make decisions locally as to how much money to invest in IAPT. But none have been prepared to open the ‘can of worms’ and insist that there is an independent assessor who at a minimum asks clients ‘compared to when you first went to IAPT are you the same, a little better, a little worse, much better, much worse? How long have you been the way you are now?
The Blatant Ignoring of Published Guidelines by IAPT
IAPT’s behaviour is in glaring contrast to that espoused in an Editorial in the most recent issue of the British Journal of Psychiatry who recommended observance of both NICE and Australian/New Zealand Guidelines for the treatment of depression with ‘robust diagnosis and re-evaluation’ at the start of treatment and at 4-6 weeks, to check that the diagnosis is correct and redirect treatment if no response. They re-iterate that the Guidelines also state that if a person is unresponsive after 4-6 weeks there is ‘a need to address problems that may not seem to be directly pertinent to depression, such as personal, social or environmental factors, and advises that other illnesses (especially personality dysfunction) should also be considered as potential contributors to depression’. No such detailed re-evaluation ever takes place in IAPT, by their own admission they do not diagnose and certainly not personality disorders.
Dr Mike Scott
Dr Mike Scott