Tag: independent assessment

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‘Go To Hell, If You Don’t Jump Through Our Hoops’

BBC-Radio-4-Womans-Hour-DownloadsDownload

that’s the take home message absorbed by a partner of an ex-soldier with PTSD, broadcast on BBC Radio 4’s Woman’s Hour yesterday, available as a podcast . Her partner was referred by his GP several times for psychological treatment, but he didn’t go though the ‘opt in’ procedure (ringing up and agreeing a telephone assessment) so in the words of the agency the referral was not ‘activated’.  He then developed a psychosis when she developed cancer and there was a further episode of psychosis before treatment got underway. But it doesn’t stop there she was never involved in the treatment despite that they could no longer sleep in the same bed because of his nightmares and his response. The treating clinicians it seems are unaware that social support is the biggest predictor of recovery from PTSD and that the disorder has a devastating impact on relationships.   Fortunately she got some help for herself from an online forum for partners of those with PTSD run by combat stress.

Clinical Commissioning Groups need to be made aware of what goes on in the mental health services they fund to the tune of £6-7 billion a year, with over £300 million being spent on IAPT each year, this amounts to billions of £’s being spent on IAPT since its’ inception, it is surely criminal that this has taken place without any independent evaluation of outcome.  

The ‘go to hell approach’ is unfortunately not confined to the process of engagement with the services, it also features in treatment – a client of mine with PTSD was told in an IAPT service the focus of the session was trauma focussed CBT/EMDR but he was concerned to talk about the devastating impact the Manchester bombing had had on his niece and he was given no such opportunity to discuss these concerns, the trauma focussed treatment proceeded relentlessly, all to no avail. 

I think it would be excellent if people sent the Radio 4 broadcast to their Clinical Commissioning Groups, the links can be accessed below, asking that they critically appraise the operation of IAPT.  Both Radio 4 and Radio 5 Live are making more broadcasts on these matters in the coming weeks and it would be great if people could disseminate the material as far as possible

https://www.england.nhs.uk/ccg-details/

Dr Mike Scott

 

 

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Clinical Commissioning Groups Need To Know What Actually Happens Behind IAPT’s Closed Doors

this can be achieved by asking local GPs to ask patients about their experience and crucially to determine what proportion of patients returned to normal functioning after referral to IAPT.

Most IAPT clients receive low intensity CBT, with only 20% recovering, half of whom relapse in a year [ Ali et al (2017)]. Only 10% of LICBT patients are stepped up to high intensity. Independent assessment suggests the overall recovery rate in IAPT is just 15%.[ Scott (2018)] https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

Results Show IAPT To Be No Better Than Pre-existing Services

A study from 2006 profiled the improvement rates of 32 primary care counselling services using the CORE Outcome Measure. (CORE-OM). The mean level of reliable improvement (including clients that also recovered)  was 72%. Across IAPT, the reliable improvement figure was 66%. But services can be re-organised to transform IAPT Scott (2018)

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

The Failure To Inspect

CCG’s and the National Audit Office show a conspicuous lack of interest in what is happening behind the closed doors of IAPT, preferring to take the Organisations marketing at face value. IAPT appears not to be accountable to the Care Quality Commission. But the CQC’s failure to effectively monitor institutions catering for those with learning difficulties and autism has unearthed a scandal, and instils little confidence in a critical appraisal of IAPT anytime soon.

An Illustration Of The Travails of a Low Intensity IAPT Recipient

Ted’s case illustrates the dire quality of service, he met IAPT in 2014, the records stated that he had been a worrier all his life, but no diagnosis was made. He was no better after 18 months of low intensity cbt. A lost soul:

Initially Ted was directed to a Psychological Wellbeing Practitioner and computerised CBT, Beating the Blues. Ted is recorded as finding the sessions helpful. At the end of LICBT it is recorded that

‘he would prefer not to access cbt again as good understanding of how his negative thoughts impact his behaviour regularly reads his previous cbt notes but implementation does not improve mood’ his psychometric test results are shown below, ‘his billboard’:

    PHQ9GAD7  
Feb 14   10   14  
 March 14 8   7
  May 14 5   9
  July 16 21 15
  August 16 20   18
     
     

At the end of his low intensity journey, there was again no assessment of his diagnostic status and he was understandably not enthusiastic about further CBT. It seems likely that few people are stepped up from low intensity to high intensity because cbt is at best seen as having limited utility.

Ali et al (2017) How durable is the effect of low intensity CBT for depression and anxiety? Remission and relapse in a longitudinal cohort study Behaviour Research and Therapy 94 (2017) 1-8

Dr Mike Scott

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IAPT’s Bonfire Night

Yesterday Pulse published its’ investigation of IAPT, it was the effigy on the bonfire despite NHS England’s protestations, see link below:

https://www.dropbox.com/s/f19vxn1h4kd37bf/IAPT%20Bonfire%20%20Night%20Revealed_%20How%20patients%20referred%20to%20mental%20health%20services%20end%20up%20back%20with%20their%20GP%20_%20Article%20_%20Pulse%20Today.pdf?dl=0

It follows close on the heels of the BBC investigation., see link http://www.bbc.co.uk/news/health-45895541

What is still not properly recognised is that despite over £1billion being spent on IAPT there has been no independent assessment and my work suggests just a 15% recovery, it is a scandal.

 

Dr Mike Scott

 

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IAPT Is a Car Crash – Transforming IAPT

IAPT (Improving Access to Psychological Therapies) is a car crash, funded by the taxpayer to the tune of £1bn, but without any insurance for the public. Staff are stressed out and there is a 10% recovery rate for clients. The National Audit Office (NAO) recently investigated IAPT but have chosen not to make its’ findings  public. I pursued a Freedom of Information Request but the NAO’s response has shed no light on their decision making. These findings are contained in my just published paper ‘Transforming IAPT’ in the Journal of Health Psychology:

 

 

the abstract reads:

Abstract

The three commentaries on my paper ‘IAPT – The Need for Radical Reform’ are agreed that Improving Access to Psychological Therapies cannot be regarded as the ‘gold standard’ for the delivery of psychological therapy services. Furthermore, they agreed that Improving Access to Psychological Therapies should not continue to mark its ‘own homework’ and should be subjected to rigorous independent evaluation scrutiny. It is a matter for a public enquiry to ascertain why £1 billion has been spent on Improving Access to Psychological Therapies without any such an independent evaluation. What is interesting is that no commentary has been forthcoming from the UK Improving Access to Psychological Therapies service nor have they shared a platform to discuss these issues. It is regrettable that the UK Government’s National Audit Office has chosen, to date, not to publish its own investigation into the integrity of Improving Access to Psychological Therapies data. Openness would be an excellent starting point for the necessary transformation of Improving Access to Psychological Therapies.

 

Dr Mike Scott

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National Audit Office IAPT Investigation ‘progress..slipped substantially….

We have not yet made a firm decision about whether or not we will publish a short report on IAPT in due course…We may choose to simply write a management report’, my communication received from the NAO today. I have made a Freedom of Information request re: the decision making and communications, which legally I should have in the next 10 days.

 

 

Given that £1bn has been spent on IAPT not to have an independent audit/assessment  seems scandalous. Claims of competing pressures is not terribly convincing.

Dr Mike Scott

 

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Is It OK That Only The Tip of The Iceberg Recover?

If only 1 in 10 people recovered from heart disease and cancer there would be uproar, but it seems to scarcely raise a professional eyebrow when independent assessment suggests that is the recovery rate for common disorders in IAPT. The blog post on ‘IAPT The Need for Radical Reform’ can be accessed by selecting below and right clicking https://connection.sagepub.com/blog/psychology/2018/02/07/on-sage-insight-improving-access-to-psychological-therapies-iapt-the-need-for-radical-reform/. One can only guess at the reasons behind the deafening silence. Perhaps it has to get as dramatic as yesterday’s BBC Panorama programme which announced a 50% increase in mental health deaths in the last 3 years.

There may be a need to move beyond professional interests to discussions with MPs, Clinical Commissioning Groups, Patient groups, Media etc

Dr Mike Scott

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‘I Have a Right to Know Whether Treatment Has Made A Real World Difference’

From a client’s point of view if they were considered ‘bad enough’, on the basis of a standardised diagnostic interview, to enter a controlled trial, the latter should also be the yardstick for judging whether their treatment was a success i.e they are ‘good enough’ not to be included in a further trial. Perhaps the researchers would like to explain to clients why there is an asymmetry between the assessment (standardised diagnostic interview) and outcome processes (the latter relying on self-report measures).  Arguably consent to treatment should only be given once the client feels this asymmetry has been properly explained! This is I think a matter for the National Institute of Health Research to consider when reviewing applicants for research funds, as a reviewer I have sometimes found submissions lacking this ‘real world’ feel.

 

Cuijpers et al meta analysis in 2016, [World Psychiatry, 15, 245-258 How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence] of 144 rcts for depression, panic disorder, generalised anxiety disorder and social anxiety disorder was restricted to studies that had used a standardised diagnostic interview for initial assessment, but the potency of the interventions were assessed only using psychometric tests. A standardised diagnostic interview is an independent reliable assessment, it is curious that outcome on this was not established and contrasted with the self-report data. It is not clear what proportion of the studies reviewed by Cuijpers reported on a re-administration of the standardised diagnostic interview. If a standardised diagnostic interview is the ‘gold standard’ for entry into an rct why is it relegated when it comes to assessing outcome. Is it that such an independent interview would be too high a bar for purported efficacious cbt treatments to clear or perhaps it is just cheaper to rely on self-report.

 

But the right to know whether treatment has made a real world difference  is not just a right to be exercised in the context of rcts, the right surely exists in routine practice. This right helps to ensure that the client is not just fodder for some numbers game. The realisation of this right forces a consideration about whether the customary sole self-report assessment and outcome measures are fit for purpose.

Dr Mike Scott

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CBT Researchers Have Abandoned Independent Blind Assesment – Beware of Findings

I have been looking in vain for the last time CBT researchers assessed outcome on the basis of independent blind assessment, which was a cornerstone of the initial randomised controlled trials of CBT.  Current CBT research is more about academic clinicians marketing their wares. Journals such as Behaviour Research and Therapy and Behavioural and Cognitive Psychotherapy and organisations such as BABCP and BPS are happily complicit in this. The message is give a subject a self-report measure to complete, it is less costly than expensive highly trained independent interviewers blinded to treatment, forget about the demand characteristics of a self-report measure ( a wish to please those who have provided a service) and don’t worry if the measure does not accurately reflect the construct under question. My psychiatric colleagues might be forgiven for saying that at least the trials of antidepressants have usually been double blinded, if since the millennium CBT studies have rarely managed to be single blinded, is it time the CBT-centric era ended? But purveyors of other psychotherapies have even more rarely bought into the importance of independent blind assessment.

The overall impact of inattention to independent blind assessment is that the case for pushing CBT is actually not as powerful as the prime movers in the field would have us believe, this may actually be a relief to struggling practitioners. For example Zhu et al (2014) [Shangai Arch Psychiatry, 26, 319-331 examined 12 randomised controlled trials of CBT for generalised anxiety disorder in which there was supposedly independent blind assessment  but in 6 of the 12 studies the main outcome measure was based on the results of a self-reported scale completed by the client (i.e outcome was not actually assessed by the blinded assessor) and concluded that the quality of the evidence supporting the conclusion that CBT was effective for GAD was poor. A meta-analysis of outcome studies  conducted by Cuijpers (2016) World Psychiatry, 15, 245-258 found that using criteria of the Cochrane risk of bias tool only 17% (24 of 144) rct’s of CBT for anxiety and depressive disorders were of high quality. Cuijper et al concluded that CBT ‘is probably effective in the treatment of MDD, GAD, PAD and SAD; that the effects are large when the control condition is waiting list, but small to moderate when it is care-as-usual or pill placebo; and that, because of the small number of high-quality trials, these effects are still
uncertain and should be considered with caution’. Only half the studies had blind assessors and it is not clear whether they were the determinants of outcome or a client completed self-report measure, the study needs further analysis. My impression is that the weakest of studies are those examining guided self-help, computer assisted CBT, (the step 2 interventions in IAPT) yet these interventions are most commonly offered.

Dr Mike Scott

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Which Guide To Mental Health

‘Did the mental  health service that you used, give you the lifestyle that you wanted?’ , answers in a new ‘Which’ guide. At present consumers are entirely at the mercy of the manufacturer’s advertising.

The views of employer’s and GP’s have potentially a greater objectivity than that of the mental health service providers. The danger is that employers can by pass serious consideration of the matter, by reminding themselves that their primary objective is profit/productivity and that provided that they can be seen as making some gesture to health and wellbeing, ‘look no  further’. In a similar way GP’s can bypass central processing of objective outcomes with a rationale that they are fully extended performing their primary function of looking after the physical health of patients, ‘so long as I can off-load mental health patients at least for a time so much the better’.

There is a pressing need to ask questions nobody wants to hear. According to George Orwell, liberty is the freedom to ask such questions. How much liberty is there really in the mental health/medical sphere?

 

Dr Mike Scott