IAPT Hoodwinks NHS England

by alleging compliance with NICE recommended evidence-based psychological treatments. But, NICE bases its’ recommendations, largely, on randomised controlled trials conducted on specific disorders, with different protocols for different disorders. It is impossible to implement NICE guidance without reliable diagnosis, but IAPT have never claimed that its’ clinicians make a diagnosis!

Even the notion of a utilising a ‘provisional diagnosis’ was jettisoned in last years IAPT Manual, (see link below) in favour of a ‘problem descriptor’:

https://www.dropbox.com/s/pgmbsoqjqmq04qz/IAPT%20Manual%202018.pdf?dl=0

On the basis of a client’s ‘problem descriptor’ the IAPT Manual requires its’ therapists to specify an ICD-10 [International Classification of Diseases 10th edition, World Health Organisation] code for a disorder, which would allegedly indicate the appropriate protocol. However there are 99 codes for Mental and Behavioural Disorders in ICD-10, there is no bridge between a ‘problem descriptor’ and a disorder. If such a leap were possible ICD-10 ( the World Health Organisation) would not have bothered to specify diagnostic criteria for the 99 conditions! Within IAPT clinicians come up with a ‘problem descriptor’ in just 2/3rds of cases, [ Clark et al (2018)] see link below:

https://www.dropbox.com/s/s7var6llzwt1otd/IAPT%20and%20Transparency%20Clark%202018.pdf?dl=0

and usually following a 20-30 minute telephone conversation, it is therefore a matter of ‘plucking a code’ from thin air for administrative purposes,


if the clinician can remember this particular ticking the box exercise.

The Clark et al (2018) study was published in the Lancet, and funded by the Wellcome Trust, and headed ‘Transparency about the outcomes of mental health services (IAPT approach): an analysis of public data’ and states:

‘Role of the funding source
The funder of the study had no role in study design, data
collection, data analysis, data interpretation, or writing of
the report. The corresponding author had full access to
all the data in the study and had final responsibility for
the decision to submit for publication’.

But there is no mention that the lead author is the leading light in IAPT, and that with one of the other authors, Lord Layard, they were the architects of IAPT. Where is the ‘transparency’ in this? In fairness in this paper they do state that a limitation of their paper is that their data is dependent entirely on client self report, but a conflict of interest stops them going on to say, that there needs to be an independent audit of IAPT, in which the diagnostic status of clients is assessed before and after treatment and at follow up.

My own independent analysis of 90 IAPT clients suggests that, contrary to IAPTs claims of a 50% recovery, just the tip of the iceberg loose their diagnostic status diagnostic status, see link below: https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

NHS England needs to clearly establish whether or not the public is ill served by IAPT and not to rely on the claims of those with a vested interest in providing the Service.

Dr Mike Scott

IAPT’s New Direction – ‘maybe, shove them all through low intensity’

that’s the take home message from a just published IAPT study conducted in the North East of England by Boyd, Reilly and Baker (2019), see link below:

https://www.dropbox.com/s/q1120m0cbvqb882/IAPT%20Stepped%20care%20model%202019.pdf?dl=0

This would mean that those with PTSD and social anxiety disorder would first fall into the orbit of low intensity interventions. Never mind that there is no empirical evidence from randomised controlled trials that these disorders respond to low intensity interventions.

Boyd, Baker and Reilly (2019) reiterate the populist myth that there is ‘sound evidence of the efficacy of low intensity interventions’ . This only becomes true if one lowers the methodological bar as low as in their own study, which was reliant entirely on self-report measures administered outside the context of a reliable diagnostic interview. These authors cite a study by Bowers et al (2013) in support of the effectiveness of low intensity interventions but these authors acknowledge that a key limitation of their study was generalisability, because patients were not reliably assessed for depression, see link below:

https://www.dropbox.com/s/24qz5pdu6dfl0ce/Low%20intensity%20initial%20severity%20doesnt%20make%20a%20difference%202013.pdf?dl=0

If the North East of England study is taken on board by IAPT, there is less need to worry about clients being on waiting lists for high intensity treatments, because they are allegedly already getting something worthwhile! Who needs high intensity therapists?

IAPT’s research and treatment is conducted on another planet from the lived experience of clients. Take the case of Tara, she suffered from depression after a fall and from a phobia about tripping, that I established with a diagnostic interview. She then had 6 IAPT face to face low intensity sessions which were described as guided self help, 2 of these involved behavioural activation. Her PHQ9 scores stayed at 19/20, which was not significantly different to when I 1st saw her with a PHQ9 score of 21. Treatment made no difference at all, though she valued the opportunity to talk she was very upset after the sessions. Tara was then put on a 3-4 month waiting list for high intensity CBT. The documentation revealed that there had been no evidence of fidelity to an evidence based treatment programme for depression and no attempt to address her phobia. Initially she had a telephone assessment with IAPT.

There is a wholesale abscence of appropriate treatment in IAPT and in practice its’ stepped care model violates continuity of care. It should try listening to clients and subjecting itself to independent audit, instead of playing with large sets of meaningless numbers, to justify funding.

Dr Mike Scott