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:

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

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

 

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

‘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

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

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