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

IAPT’s Training Of Therapist’s On Working With Long Term Physical Conditions Muddies The Waters on Efficacy

the evidence base that CBT works with the psychological sequelae of physical conditions is of a wholly different order to that for depression and anxiety disorders (the original remit of IAPT). As a consequence therapists entering this area could become quickly demoralised, increasing the already high rates of burnout. To my knowledge, there are no studies in the LTC area that a) compare the CBT treatment with an active credible attention control group and b) involve independent assessment by a person blind to treatment. Rather outcome assessments are entirely by self report measures such as the PHQ9 and GAD7 of dubious relevance to the destabilisation that can arise from having an LTC.

Training appears to focus on what the therapist should do and the needed competences. But therapists should be aware that these are largely expert consensus statements, the least credible type of evidence and not something derived from an established evidence base.

There are all sorts of minefields in this area not least the diagnostic confusion between say cancer and depression both result in tiredness, insomnia and loss of appetite. Yet training appears not to address this.

One is reminded of the adage ‘fools rush in where angels fear to tread’, is it enticement by empire building and the availability of funds?.

Dr Mike Scott

IAPT and Rudolph

Rudolph had a very shiny nose, in a routine consultation with  his GP, Dr Touchy-Feely, the latter said that it was medically unexplained and he could be referred/or refer himself to IAPT.

He replied that it was a long term physical condition and he didn’t think a psychological service was appropriate. The GP opined that he might have persistent somatic symptom disorder and entered this in his notes. . Later that day Rudolph had a telephone conversation with Father Christmas who wondered whether he could help him out that evening. Rudolph mentioned in passing his conversation with the  GP. Father Christmas observed that everyone knew he had a very shiny nose and could on occasion feel left out or ridiculed but was this really a psychological problem, didn’t IAPT have enough to do with all the anxious and depressed people! Rudolph replied sheepishly, perhaps I should ring IAPT in the New Year, after all the GP is saying I have got persistent somatic disorder. Father Christmas replied Dr Touchy-Feely, does not know what evidence based criteria are for anything and added whimsically ‘he doesn’t even believe in me’.

Have a great Christmas Folks

 

Dr Mike Scott