and the added value of low intensity IAPT is?

compared to how people would have got on anyway if not referred to IAPT (in economist terms the appropriate counterfactual), the ‘added value’ has not been demonstrated. Yet most people receive a low intensity intervention such as computerised CBT, guided self help or groupwork.

I could find no independent outcome assessors involved in the randomised controlled trials of low intensity interventions that the NICE guidance largely relies on. Instead reliance has been placed on IAPT’s marking and marketing of its’ own homework.

In a review of randomised controlled trials published in 4 medical journals Kahan, Rehal and Cro (2015) only a quarter (26%) involved blinded outcome assessment. These authors write ‘Previous reviews have found that unblinded outcome assessment can lead to estimates of treatment
effect that are exaggerated between 27% and 68%’ see link below:

But the position appears worse when it comes to psychological therapies with no reliable rcts for low intensity interventions, and with regards to high intensity interventions the few blind outcome assesments are clustered around depression, the anxiety disorders and PTSD. Since the millenium there has been a drift away from the use of outcome assessors, this makes research cheaper, it is much easier to massage statistics to give a positive hue, the originators of an intervention and those with a vested interest are given a free hand.

Researchers on IAPT [seee Bower et al (2013)] play fast and loose with Cochrane risk of bias tool, see link below:

and jettison the need for independent blind assessment implicit in the tool on the spurious grounds that ‘most outcomes are self-reported’ see link below:

Looked at from the perspective of independent outcome assessment the claims for low intensity interventions look spurious and the evidence base for high intensity interventions is more circumscribed than BABCP conferences or IAPT would suggest.

The IAPT Manual published last year recommends extension of the service to irritable bowel syndrome, chronic fatigue syndrome, chronic pain and medically unexplained symptoms not otherwise specified but makes no mention at all of the need for independent blind assessment of outcome, instead it suggests simply what self-report measures should be administered. See link below:

Yet another marketing opportunity, when we need real world answers, how many people said to an impartial observer that they were back to their usual selves after the intervention? how long did this last?

Dr Mike Scott

IAPT’s Sojourn Into The Quagmire

Putting patients with medically unexplained symptoms, such as CFS (chronic fatigue sundrome) and IBS (irritable bowel syndrone) on a mental health pathway, is a fraught endeavour, can there be any certainty that physical investigations of their difficulty will continue? Who will provide that certainty, surely not IAPT( Improving Access to Psychological Therapies) workers? Perhaps GP’s or gastroenterologists – doubtful?

 IAPT’s focus is on psychological interventions, most patients with long term physical conditions will find it incongruous to be offered a mental health intervention, unless there is a clear additional problem such as panic disorder. There is a danger that those with LTC’s will feel the normal emotional distress associated with their long standing problem is being psycho-pathologised.  

Whilst some with LTC’s may wish to avail themselves of psychological help, many will do so at the behest of a GP or gastronetrologist, believing that they would not be suggesting it, if it were not evidence based. Yet there is in fact a weak evidence base for CBT for these conditions compared to that which obtains for the anxiety disorders and depression.

Psychological interventions in the LTC area serve to distract from improving the poor quality services in areas in which CBT could make a real world difference. Rather they have a novelty value and attract funding/empire building.

Dr Mike Scott